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The Oregon Administrative Rules contain OARs filed through September 15, 2014
 
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OREGON HEALTH AUTHORITY,
PUBLIC HEALTH DIVISION

 

DIVISION 520

HOSPITALS, GENERALLY

Hospital Services

333-520-0000

Applicability

Whether a hospital is required to provide a service listed in this division depends on a hospital’s classification, as those classifications are described in OAR 333-500-0032. If a hospital chooses to provide a service that is not required it shall comply with the applicable rule in this division.

Stat. Auth.: ORS 441.055 & 442.015
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(1) & (2); HD 21-1993, f. & cert. ef. 10-28-93; PH 11-2009, f. & cert. ef. 10-1-09

333-520-0020

Dietary Services

(1) All hospitals, regardless of classification, shall comply with this rule.

(2) A hospital shall:

(a) Have an organized dietary department, directed by qualified personnel, that conforms to the requirements in OAR 333-150-0000, the Food Sanitation Rules.

(b) Employ supportive personnel competent to carry out the functions of the dietary service, including a full-time director with overall supervisory responsibility for the dietary service and who is:

(A) A qualified dietitian who is registered by the Commission on Dietetic Registration of the American Dietetic Association;

(B) A person who has received a baccalaureate or higher degree with major studies in food, nutrition, diet therapy or food service management and has at least one year of supervisory experience in a health care dietetic service, and participates in continuing education related to the dietetic profession;

(C) A graduate of a dietetic technician or dietetic assistant training program, corresponding or classroom, approved by the American Dietetic Association;

(D) A graduate of a state approved course that provides 90 or more hours of classroom instruction in food service supervision and has one year's experience as a supervisor in a health care institution; or

(E) Has training and experience in food service supervision and management in a military service equivalent in content to one of the above criteria for qualifying.

(c) Contract with a dietician with the qualifications listed in paragraph (2)(b)(B) of this rule, if the Director is not a qualified dietitian under paragraph (2)(b)(A) of this rule, and:

(A) Consult at least quarterly with the contractor;

(B) Have on file a contract signed by the consultant and the hospital administrator stating the relationship of the consultant to the hospital, services to be provided, length of contract, terms and hours; and

(C) Require the contractor to submit quarterly reports to the hospital administrator and the committee, council or other reviewing body designated by the hospital as having responsibility for dietary services that include:

(i) The date(s) of visit(s) and length of time spent on premises;

(ii) Staff members seen;

(iii) Services performed;

(iv) Action taken on previous reports;

(v) Problems identified; and

(vi) Recommended action and distribution of the report.

(d) Require the on-site visits of the Consulting Dietitian to be of sufficient duration and frequency to review dietetic systems and assure quality food to the patient.

(e) Provide dietetic services to patients in accordance with a written order by the responsible physician, or other health care practitioner authorized within the scope of his or her professional license, and record appropriate dietetic information in the patient's medical record including the following:

(A) Timely and periodic assessments of the patient's nutrient intake and tolerance to the prescribed diet modification, including the effect of the patient's appetite and food habits on food intake;

(B) A description of the diet instructions given to the patient or family and assessment of their diet knowledge;

(C) A description or copy of the diet information forwarded to another institution upon patient discharge; and

(D) Nutritional care follow-up with the patient’s health care practitioner or a health care agency.

(f) Regularly review and evaluate the quality and appropriateness of nutritional care provided by the dietetic service including the nutritional adequacy of all menus.

(g) Ensure that the Dietetic Service is represented on hospital committees concerned with nutritional care.

(h) Serve food that has an appetizing appearance, is palatable, is served at proper temperature and is cooked and served in such a way as to retain the nutrient value of food.

(i) Restrict admittance to the kitchen area to those who must enter to perform assigned duties.

(j) Develop written procedures for cleaning equipment and work areas and enforce those procedures.

Stat. Auth.: ORS 441.055 & 442.015
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(7); HD 21-1993, f. & cert. ef. 10-28-93; HD 2-2000, f. & cert. ef. 2-15-00; PH 11-2009, f. & cert. ef. 10-1-09

333-520-0030

Laboratory Services

(1) All hospitals, regardless of classification, are required to comply with this rule.

(2) A hospital shall:

(a) Have on-site or use a licensed clinical laboratory that meets the requirements of ORS 438.010 through 438.510 and OAR 333-024; or has been issued a valid certificate from the federal government under the Clinical Laboratory Improvement Amendments of 1988 (CLIA 88), and that provides timely laboratory services to support a hospital’s medical, surgical and other services.

(b) Have on staff or under contract a clinical pathologist to oversee clinical laboratory testing including pathology services.

(c) Have appropriately trained laboratory staff on-site or on-call 24 hours a day, 7 days a week (24/7).

(3) If a hospital performs clinical laboratory testing at point of care, the requirements of subsection (2)(a) of this rule shall be met and the hospital shall:

(a) Have a written policy for point of care testing that is reviewed by a committee, council or other reviewing body designated by the hospital as having responsibility for laboratory services;

(b) Designate a person responsible for the direction and supervision of this testing;

(c) Assure that in addition to manufacturers instructions there are procedures to cover specimen collection and preservation;

(d) Maintain documentation of staff specific orientation, training, and ongoing competency for two years; and

(e) Maintain documentation of instrument calibration, quality control records and preventative maintenance for two years.

(4) Blood banking transfusion records shall be maintained and kept for 20 years.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(8); HD 21-1993, f. & cert. ef. 10-28-93; PH 11-2009, f. & cert. ef. 10-1-09

333-520-0035

Pharmacy Services

(1) A general hospital is required to have an on site pharmacy and a pharmacist on call 24/7 to staff the pharmacy.

(2) Low occupancy acute care hospitals and mental or psychiatric hospitals may have an on-site pharmacy or a drug room.

(3) Low occupancy acute care hospitals and mental or psychiatric hospitals shall have appropriately trained pharmacy staff on-site or on-call 24/7.

(4) A pharmacy in a hospital shall comply with the applicable requirements in ORS Chapter 689 and OAR chapter 855, including 855-041-0120 through 855-041-0132.

(5) A drug room in a hospital shall comply with the applicable requirements in ORS Chapter 689 and OAR 855-041-0135 through 855-041-0140.

(6) All hospitals, regardless of classification shall dispose of old medications, including special prescriptions for patients who have left the hospital, by incineration or another equally effective method, except narcotics and other drugs under the drug abuse law, which shall be handled in the manner prescribed by the Drug Enforcement Administration of the U.S. Department of Justice.

Stat. Auth.: ORS 441.055
Stats Implemented: ORS 441.055 & 442.015
Hist.: PH 11-2009, f. & cert. ef. 10-1-09; PH 17-2012, f. 12-20-12, cert. ef. 1-1-13

333-520-0040

Radiology Services

(1) All hospitals, regardless of classification shall have on-site or contract radiology services that:

(a) Comply with ORS Chapter 453 and its applicable implementing rules;

(b) Support the hospital’s medical, surgical and other services; and

(c) Are available on a timely basis.

(2) All hospitals, regardless of classification, shall:

(a) Employ or contract with a radiologist to certify the quality and adequacy of all radiology; and

(b) Have on-site or in-house radiology staff available 24/7.

Stat. Auth.: ORS 441.055 & 442.015
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(9); HD 21-1993, f. & cert. ef. 10-28-93; PH 11-2009, f. & cert. ef. 10-1-09

333-520-0050

Surgery Services

(1) General hospitals are required to comply with this rule. A low occupancy acute care or mental or psychiatric hospital shall comply with this rule if it offers surgery services.

(2) A hospital that provides surgical services shall have operating rooms that conform to the applicable requirements in OAR chapter 333, division 535.

(3) A hospital’s operating rooms must be supervised by an experienced registered nurse or doctor of medicine or osteopathy.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(10) & (11); HD 21-1993, f. & cert. ef. 10-28-93; PH 11-2009, f. & cert. ef. 10-1-09; PH 17-2012, f. 12-20-12, cert. ef. 1-1-13

333-520-0060

Maternity Services

(1) General hospitals are required to comply with this rule. A low occupancy acute care hospital shall comply with this rule if it offers maternity services.

(2) A hospital that provides maternity services shall have separate maternity facilities and a maternity care department that:

(a) Has labor, delivery, recovery, postpartum, and nursery rooms that conform to the applicable requirements of OAR chapter 333, division 535;

(b) Requires every person in the delivery room during a delivery to be appropriately attired according to the hospital's Infection Control Policy;

(c) Has appropriate resuscitation equipment immediately available to rooms where deliveries are planned and where newborn infants are kept;

(d) Has a warmed blanket or incubator for newborns to prevent thermal loss;

(e) Has incubators for premature infants equipped with a governor to control the flow of oxygen at 40 percent or under, and an oxygen analyzer;

(f) Has an accurate scale for weighing of infants; and

(g) Includes a nursery and a separate bassinet for each infant with a clean mattress covered with suitable sheeting, washable pads, and bed linen that is kept clean at all times.

(3) A health care practitioner attending the birth of a newborn shall evaluate and treat a newborn at risk for chlamydial or gonococcal ophthalmia neonatorum in accordance with OAR 333-019-0036.

(4) A parent or legal representative that refuses to allow prophylaxis for an infant shall be informed by the attending health care practitioner of the risks of the refusal and must sign a witnessed affidavit that attests they have been so informed and nonetheless refuse to allow prophylaxis.

(5) A hospital shall ensure that all newborns are given Vitamin K at birth as required by ORS 433.303 through 433.314.

(a) A physician or midwife attending the mother at the birth of the child shall be responsible for ensuring that the newborn infant receives Vitamin K within 24 hours of birth to protect the infant against hemorrhagic disease of the newborn.

(b) The Vitamin K forms suitable for use are:

(A) Vitamin K 1 (Phytonadione) for oral or injectable use;

(B) Mephyton for oral use; or

(C) Aquamephyton or konakion for injectable use.

(c) A parent may, after being provided a full and clear explanation, decline to permit the administration of Vitamin K based on religious tenets and practices. If a parent or legal representative declines Vitamin K, the parent shall sign a form acknowledging his or her understanding of the reason for administration of Vitamin K and possible adverse consequences in the presence of a person who witnessed the instruction of the parent, who shall also sign the form. The form shall become a part of the medical record of the newborn infant.

(6) A hospital shall ensure that every newborn infant born in the hospital is tested for Metabolic Diseases as required by OAR 333-024-0210 through 333-024-0235 and instructions to the parents or legal representative regarding the testing that be documented in the medical record.

(7) A hospital shall ensure that every newborn infant born in the hospital receives a Newborn Hearing Screening Test as required by ORS 433.321 and OAR chapter 333, division 20.

(8) A hospital must perform pulse oximetry screening on every newborn infant delivered at the hospital before discharging the newborn infant in conformance with the following requirements:

(a) The pulse oximetry screening must be performed using evidence-based guidelines such as those recommended by Strategies for Implementing Screening for Critical Congenital Heart Disease, AR Kemper et al., Pediatrics 2011;128(5): e1259–1267.

(b) The hospital must have policies and procedures based on the guidelines required by subsection (a) of this section for:

(A) Determining what is considered a positive screening result; and

(B) Determining what follow-up services, treatment, or referrals must be provided if a newborn infant has a positive screening result.

(c) A Federal Drug Administration (FDA) approved motion tolerant pulse oximeter must be used.

(d) The pulse oximetry screening must be performed no sooner than 24 hours after birth or as close to discharge of the newborn infant as possible.

(e) If a newborn infant is admitted to a hospital as the result of a transfer from another hospital or Birthing Center before a pulse oximetry screening is performed, the hospital from which the newborn infant is discharged to home is responsible for performing the screening.

(f) The hospital must provide the following notifications and document them in the newborn infant’s medical record:

(A) Prior to the pulse oximetry screening, notify a parent or legal representative of the newborn about the reasons for the screening and the risks and consequences of not screening.

(B) Following the pulse oximetry screening, notify the health care provider responsible for the newborn infant and the infant’s primary care provider of the results of the screening.

(C) Following the pulse oximetry screening and prior to discharge, notify a parent or legal representative of the newborn infant of the screening result, an explanation of its meaning and, if it is a positive screening result, provide information about the importance of timely diagnosis and intervention.

(g) A parent or legal representative of a newborn infant may decline pulse oximetry screening and, if screening is declined, the hospital must document the declination in the newborn infant’s medical record.

(h) Following the pulse oximetry screening, the hospital, in accordance with the applicable standard of care, must provide any appropriate follow-up services or treatment for the newborn infant if necessary or provide a referral to a parent or legal representative of the newborn for follow-up services or treatment if necessary.

(i) The hospital must document in the newborn infant’s medical record that the screening was performed, the screening result, the names of the health care providers who were notified of the screening result, and any follow-up services or treatment or referral for services or treatment.

(j) No newborn infant may be refused screening because of the inability of a parent or legal representative to pay for the screening.

(9) Every infant born in a hospital shall be marked for identification before the infant is removed from the place of delivery and such identification shall not be removed from the infant until the infant is discharged.

(10) A hospital shall not admit visitors to a delivery room, maternity rooms, wards, units, or the nursery except in accordance with the hospital's visiting policy.

(11) A hospital shall ensure that persons entering the nursery are attired according to the hospital infection control policy and that hands are washed before touching an infant.

(12) A hospital shall follow its infection control policy when handling and storing linens.

(13) Formula feedings and any other feedings shall be given only as prescribed in writing by the physician or certified nurse midwife.

(14) A hospital shall maintain and preserve a log of births giving date of birth, name of newborn, and mother's name and chart number, in addition to complying with the requirements of the Authority’s Center for Health Statistics.

(15) A hospital may use a part of the maternity department for selected, non-communicable non-obstetrical patients as defined by hospital policy and approved by the hospital's infection control program under the following conditions:

(a) Patients admitted or transferred to the maternity department shall be instructed by appropriate maternity service personnel as to their responsibilities regarding use of the facility.

(b) Patients admitted to the maternity department shall be limited to obstetrical patients admitted for delivery, patients with obstetric complications, and selected non-communicable, non-obstetrical patients.

(c) Obstetrical patients and medical/surgical patients shall not occupy the same room.

(d) If necessary, one or more medical/surgical patients shall be transferred to another service in order to admit obstetrical patients.

(16) A hospital shall adhere strictly to the guidelines for standard precautions developed by the Hospital Infection Control Practices Advisory Committee (HICPAC) when caring for obstetrical patients with infectious conditions. Patients with infectious conditions requiring strict isolation according to the above guidelines shall be transferred out of the maternity department following delivery, and given care in an area of the hospital where that isolation can be provided. If a maternity patient is found to have an infectious condition during surgery or delivery, the patient shall be returned to the maternity department and isolated according to hospital infection control policy.

(17) A delivery room suite may be used for surgical procedures on non-obstetrical patients if approved by the Chief of Obstetrics in accordance with medical staff rules and regulations.

(18) A hospital with maternity services may place stable postpartum patients and stable newborns, as those terms are defined in OAR 333-500-0010, on another acute care unit on a periodic basis under the following conditions:

(a) When a postpartum patient or newborn to be transferred out of the OB unit meet the hospital's criteria for care on another unit as described in this rule;

(b) Where the decision to place a postpartum patient or newborn on another unit is based on currently accepted postpartum and newborn care standards and the ability of that unit to meet the needs of the patient; and

(c) When nursing staff on the non-OB unit have received training required by this rule and have demonstrated continuing competence.

(19) A hospital that provides care to postpartum patients and newborns on non-OB units shall:

(a) Develop and implement policies and procedures that include but are not limited to:

(A) The transfer of postpartum patients and newborns to non-OB units including a delineation of the authority for medical, clinical and administrative nursing staff, and, when applicable, nurse practitioner staff to make the decision;

(B) Staffing guidelines for the nursing care of postpartum patients and newborns on the non-OB unit;

(C) Provision of information to maternity patients of possible or intended placement on a non-OB unit;

(D) Provision of consumer information related to the availability and location of specialty maternity services;

(E) Infection control practices including the use of standard precautions;

(F) Procedures for patient placement, privacy, and safety that prohibit postpartum patients and newborns from occupying the same room as non-obstetrical patients;

(G) Protocols for the placement of newborns without mothers;

(H) Procedures to assure the inclusion of the care of postpartum patients and newborns on non-OB units in the hospital's quality assurance program; and

(I) Delineation of hospital protocols for the return of postpartum patients and newborns to the OB unit, including addressing situations when safe care can no longer be provided on the non-OB unit.

(b) Develop and implement staff training, continuing education, and continuing competency program that includes but is not limited to:

(A) Postpartum nursing care;

(B) Nursing care of the newborn;

(C) Newborn resuscitation;

(D) Newborn feeding;

(E) Maternal and family education;

(F) Infection control practices including the use of standard precautions; and

(G) Maternity services policies and procedures including those required in subsection (19)(a) of this rule.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(12), (13), & (14); HD 21-1993, f. & cert. ef. 10-28-93; HD 30-1994, f. & cert. ef. 12-13-94; HD 2-2000, f. & cert. ef. 2-15-00; OHD 3-2001, f. & cert. ef. 3-16-01; PH 11-2009, f. & cert. ef. 10-1-09; PH 17-2012, f. 12-20-12, cert. ef. 1-1-13; PH 18-2013(Temp), f. 12-31-13, cert. ef. 1-1-14 thru 6-29-14; PH 18-2014, f. & cert. ef. 6-17-14

333-520-0070

Emergency Department and Emergency Services

(1) Hospitals classified as general and low occupancy acute care shall have an emergency department that provides emergency services.

(2) A hospital with an emergency department shall:

(a) Provide emergency services 24 hours a day including providing immediate life saving intervention, resuscitation, and stabilization;

(b) Have a licensed health care practitioner with admitting privileges on-call, 24 hours a day;

(c) Have at least one registered nurse, appropriately trained to provide emergency care within the emergency service area;

(d) Have adequate medical staff and other ancillary personnel necessary to provide emergency care either present in the emergency service area or available 24 hours a day in adequate numbers to respond promptly;

(e) Ensure that when surgical, laboratory, and X-ray procedures are indicated and ordered, due regard is given to promptness in carrying them out;

(f) Ensure that it has items for resuscitation, stabilization, and basic emergency medical care, including airway equipment and cardiac resuscitation medications and supplies for adults, children and infants;

(g) Have a communication system and personnel available 24 hours a day to ensure rapid communication with ambulances and departments of the hospital including, but not limited to, X-ray, laboratory, and surgery;

(h) Have a plan for emergency care based on community needs and on hospital capabilities which sets forth policies, procedures and protocols for prompt assessment, treatment and transfer of ill or injured persons, including specifying the response time permissible for medical staff and other ancillary personnel;

(i) Provide for the prompt transfer of patients, as necessary, to an appropriate facility in accordance with transfer agreements, approved trauma system plans, consideration of patient choice, and consent of the receiving facility;

(j) Have written transfer agreements for the care of injured or ill persons if the hospital does not provide the type of care needed;

(k) Ensure that personnel are able to provide prompt and appropriate instruction to ambulance personnel regarding triage, treatment and transportation;

(l) Develop, maintain, and implement current written policies and procedure that include clearly-defined roles, responsibilities, and reporting lines for emergency service personnel;

(m) Maintain emergency records in accordance with OAR 333-505-0050;

(n) Establish a committee of the emergency department staff who shall at least quarterly, review emergency services by evaluating the quality of emergency medical care given, and engage in ongoing development, implementation, and follow-up on corrective action plans; and

(o) Ensure it provides appropriate training programs for hospital emergency service personnel.

(3) If a hospital is also designated or categorized as a trauma hospital under ORS 431.607 through 431.671, the hospital shall:

(a) Comply with the applicable provisions in OAR chapter 333, division 200 through 205;

(b) Report trauma data to the State Trauma Registry in accordance with the requirements of the Division; and

(c) Fully cooperate with the approved area trauma system plan.

(4) An officer or employee of a general or low occupancy acute care hospital licensed by the Division may not deny a person an appropriate medical screening examination needed to determine whether the person is in need of emergency medical services if the screening is within the capability of the hospital, including ancillary services routinely available to the emergency department.

(5) An officer or employee of any hospital licensed by the Division may not deny services to a person diagnosed by a physician as being in need of emergency medical services because the person is unable to establish the ability to pay for the services if those emergency medical services are customarily provided at the hospital.

(6) A mental or psychiatric hospital shall assess and provide initial treatment to a person that presents to the hospital with an emergency medical condition, as that term is defined in 42 CFR 489.24. The hospital shall admit the person if the emergency medical condition falls within the specialty services provided by the hospital under OAR chapter 333, division 525.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HB 183, f. & ef. 5-26-66; HB 209, f. 12-18-68; HB 252, f. 7-22-70, ef. 8-25-70; HD 25, f. 10-20-72, ef. 11-1-72; HD 72, f. 11-7-74, ef. 12-11-74; HD 7-1979, f. & ef. 7-17-79; HD 11-1980, f. & ef. 9-10-80; Renumbered from 333-023-0126; HD 29-1988, f. 12-29-88, cert. ef. 1-1-89, Renumbered from 333-072-0005(15) & (16); HD 21-1993, f. & cert. ef. 10-28-93; HD 2-2000, f. & cert. ef. 2-15-00; PH 11-2009, f. & cert. ef. 10-1-09; PH 17-2012, f. 12-20-12, cert. ef. 1-1-13

333-520-0075

Respite Care

(1) A general hospital or low occupancy acute care hospital may provide respite services.

(2) Application for permission to accept respite care guests shall be made to the Division on a form provided by the Division.

(3) The Division may grant permission for a hospital to accept respite care guests if:

(a) Admittance of a respite care patient will not interfere with the care to be provided to other patients.

(b) The hospital has written policies that address respite care services that are evaluated annually, and are implemented and followed by hospital staff. These policies shall address:

(A) Type(s) of guests who may be admitted;

(B) Scope of services provided;

(C) Length of stay (which shall not exceed 30 consecutive days);

(D) Emergency care provisions;

(E) Written criteria delineating situations which necessitate physician contact;

(F) Written criteria delineating situations which necessitate family or personal representative contact; and

(G) Written criteria for administration and storage of medications.

(4) Sufficient physical space shall be provided for respite care guests for dining and activities. Space shall allow for mobility and exercise. Respite care areas shall provide for bathing and toileting facilities. Each respite care guest shall have an assigned licensed bed and storage area for personal belongings. Regular acute care licensed beds may be utilized for respite care guests; however, respite care guests shall not share a room with acute care patients. Activities which are suitable to the needs of respite care guests shall be provided.

(5) Respite care guest records:

(a) There shall be available for each respite care guest an admission summary form containing the guest's name, address, telephone number, and other demographic data including the name, address, and telephone number of attending qualified member of the medical staff and nearest relative or personal representative.

(b) The guest record shall include admission evaluation, medication administration record, flow sheets, assessments, and progress notes as required by paragraph (7)(d)(C) of this rule.

(6) Medical supervision:

(a) The name and telephone number of the guest's physician or other qualified member of the medical staff shall be readily available to respite care staff members.

(b) A qualified health care practitioner order shall not be required for admission to respite care.

(c) An order from a qualified health care practitioner authorized by law shall be required for any new medications or treatments.

(7) Registered nurse (RN) supervision:

(a) Respite care services shall be supervised by an RN.

(b) The RN shall review the guest's medications and usual diet and verify information within four hours of admission. Documented intake information shall include, but not be limited to, current medications, dietary needs, level of ability for assisted or self-care, and any other information germane to the guest's condition. The RN shall document an evaluation of the guest's need on admission.

(c) If the respite care guest stays seven days or more, a nursing assessment shall be performed and documented by the RN on the eighth day and weekly thereafter. If the respite care guest is initially planning to stay for seven or more days, a nursing assessment shall be performed and documented by an RN on admission and weekly thereafter.

(d) In addition to the documentation required in subsections (7)(b) and (c) of this rule, the hospital shall maintain:

(A) Activities of daily living (ADL) sheet by shift;

(B) Medication administration record; and

(C) Weekly progress notes by caregivers.

(8) Medication administration:

(a) Respite care guests taking medication prescribed by their physicians or other qualified health care practitioners may bring such medications in the original containers to the facility. All prescription medications brought in by guests shall be verified by a pharmacist prior to administration.

(b) All medications shall be clearly labeled with the name of the medication, strength/dose, directions for administration, expiration date, and guest's name.

(c) No outdated medication shall be administered.

(d) Any change or alteration in medication shall require an order from a health care practitioner authorized by law.

(e) Medications may be independently self-administered, self-administered under supervision of an RN/LPN, or administered by an RN, LPN, or certified medication aide, depending on the guest's ability. The type of administration shall be determined by the RN. This determination shall be in writing. Medications administered and the type of administration shall be documented on medication administration records.

(9) Quality assurance:

(a) Respite care services shall be included in the hospital-wide quality assurance program.

(b) A mechanism for quality assurance activities shall be defined and implemented.

(c) There shall be documentation of ongoing quality assurance activities.

(d) Quality assurance activities shall be reported to the hospital committee, council, or other reviewing body designated by the hospital as having responsibility for quality assurance.

(10) Nothing in this rule shall be interpreted for creating any obligations for third party payors to reimburse hospital respite care.

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: HD 21-1993, f. & cert. ef. 10-28-93; HD 2-2000, f. & cert. ef. 2-15-00; PH 11-2009, f. & cert. ef. 10-1-09

333-520-0120

Psychiatric Services

A hospital classified as mental or psychiatric or a general or low occupancy acute care hospital that provides inpatient psychiatric services and has an inpatient psychiatric unit shall comply with OAR 333-525-0000(2) through (10).

Stat. Auth.: ORS 441.055
Stats. Implemented: ORS 441.055 & 442.015
Hist.: PH 11-2009, f. & cert. ef. 10-1-09

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