Oregon Administrative Code

333-500-0090 Adoption by Reference All rules, standards and publications referred to in OAR 333-500 through 535 are incorporated by reference. Copies are available for inspection in the Oregon Health Authority during office hours. Where publications are in conflict with the rules…

333-501-0005 Complaints (1) Any person may make a complaint verbally or in writing to the Oregon Health Authority (Authority) regarding an allegation against a hospital of a violation of any health care facility licensing law or condition of participation. (2) The identity of a p…

333-501-0010 Investigations (1) As soon as practicable after receiving a complaint, taking into consideration the nature of the complaint, Oregon Health Authority (Authority) staff will begin an investigation. (2) A hospital shall permit Authority staff access to the facility dur…

333-501-0015 Surveys (1) The Oregon Health Authority (Authority) shall, in addition to any investigations conducted under OAR 333-501-0010, conduct at least one in-person licensing survey of each hospital every three years to determine compliance with health care facility licensi…

333-501-0020 Violations In addition to non-compliance with any health care facility licensing law or condition of participation, it is a violation to: (1) Refuse to cooperate with an investigation or survey, including but not limited to failure to permit Oregon Health Authority (…

333-501-0025 Informal Enforcement (1) If, during an investigation or survey Oregon Health Authority (Authority) staff document violations of health care facility licensing laws or conditions of participation, the Authority may issue a statement of deficiencies that cites the law …

333-501-0030 Formal Enforcement (1) If, during an investigation or survey Oregon Health Authority (Authority) staff document substantial failure to comply with health care facility licensing laws, conditions of participation or if a hospital fails to pay a civil penalty imposed u…

333-501-0050 Civil Penalties for Violation of Smoking Prohibition (1) If the Oregon Health Authority (Authority) determines that an administrator or person in charge of a hospital permits a person to smoke tobacco in a hospital or within 10 feet of a doorway, open window or venti…

333-501-0055 Civil Penalties, Generally (1) This rule does not apply to civil penalties for violations of ORS 441.763, 441.770, 441.815, or 435.254 or rules adopted to implement these statutes. (2) A person that violates a health care facility licensing law, including OAR 333-501…

333-501-0060 Approval of Accrediting Organizations (1) An accrediting organization may request approval by the Oregon Health Authority (Authority) to ensure that hospitals meet state licensing standards. (2) An accrediting organization shall request approval in writing and shall …

333-503-0002 Applicability These rules apply to hospital staffing pursuant to ORS 441.760 to 441.795. Statutory/Other Authority: ORS 413.042 & ORS 441.760 - 441.795 Statutes/Other Implemented: ORS 441.760 - 441.795 History: PH 46-2024, adopt filed 05/15/2024, effective 05/15/2024…

333-503-0005 Definitions (1) The definitions in ORS 441.760 apply to these rules. (2) For the purposes of these rules and for the processing of complaints, the Oregon Health Authority (Authority) shall apply the definitions below: (a) “Adopt a plan” means: (A) For purposes of ado…

333-503-0010 Filing Hospital Staffing Complaints (1) Only a hospital staff person or an exclusive representative of a hospital staff person may submit a complaint. (2) Complaints must be submitted through the Oregon Health Authority (Authority)’s website, on a form prescribed by …

333-503-0020 Processing Complaints (1) The Oregon Health Authority (Authority) will only investigate complaints that are: (a) Valid complaints; and (b) Submitted within 60 calendar days of the violation alleged in the complaint. (2) Once the Authority has determined that a compla…

333-503-0050 Hospital Staffing Plan Waiver (1) A hospital may request a waiver under ORS 441.778 to the written hospital-wide staffing plan requirements in ORS 441.760 to 441.795, if the waiver is necessary to ensure that the hospital is staffed to meet the health care needs of i…

333-503-0060 Nursing Staff Member Overtime For purposes of determining hospital compliance with ORS 441.770, and whether a hospital has a violation under ORS 441.792(2)(h): (1) “Emergency circumstances” includes: (a) Sudden and unforeseen adverse weather conditions; (b) An infect…

333-505-0001 Applicability These rules apply to all hospitals, regardless of classification. Statutory/Other Authority: ORS 441.025 Statutes/Other Implemented: 441.025 History: PH 17-2012, f. 12-20-12, cert. ef. 1-1-13 PH 11-2009, f. & cert. ef. 10-1-09 HD 21-1993, f. & cert. ef.…

333-505-0005 Governing Body Responsibility (1) In a multi-hospital system, one governing body may oversee multiple hospitals. (2) The governing body of a hospital shall be responsible for the operation of the hospital, the selection of the medical staff and the quality of care re…

333-505-0007 Health Care Practitioner Credentialing Each hospital shall comply with the health care practitioner and telemedicine provider credentialing requirements in accordance with OAR chapter 409, division 045. Statutory/Other Authority: ORS 441.056 Statutes/Other Implemente…

333-505-0010 Administrator (1) Each hospital shall employ or contract with a chief executive officer (CEO) or administrator who is responsible for the operation of the hospital and hospital based services in a manner commensurate with the authority conferred by the governing body…

333-505-0020 Medical Staff (1) The medical staff is responsible for reviewing the professional practices of the hospital for the purpose of reducing morbidity and mortality and for the improvement of patient care, and is accountable to the governing body. (2) The hospital’s medic…

333-505-0030 Organization, Hospital Policies (1) A hospital's internal organization shall be structured to include appropriate departments and services consistent with the needs of its defined community. (2) A hospital shall adopt and maintain clearly written definitions of its o…

333-505-0033 Patient Rights (1) A hospital shall comply with the requirements for patients' rights as set forth in 42 CFR 482.13. (2) As used in sections (3) through (9) of this rule: (a) "Patient" means a patient admitted to a hospital or seeking medical evaluation and care in a…

333-505-0036 Hospital Requirements During Emergency Impacting Standard of Care (1) This rule does not circumvent or supersede Centers for Medicare and Medicaid Services (CMS) requirements to meet the needs of the facility and care of patients. (2) For purposes of this rule: (a) "…

333-505-0040 Personnel (1) A hospital shall: (a) Maintain a sufficient number of qualified personnel to provide effective patient care and all other related services. (b) Have written personnel policies and procedures that are available to personnel. (c) Provide orientation for n…

333-505-0045 Potential Threat or Disruptive Behavior Flagging Systems (1) As used in this rule: (a) "Authorized staff" means the personnel who are responsible for creating and tracking electronic health record flags. (b) "Disruptive behavior" includes physically aggressive, haras…

333-505-0050 Medical Records (1) A medical record shall be maintained for every patient admitted for care in a hospital. (2) A legible reproducible medical record shall include, but is not limited to (as applicable): (a) Admitting identification data including date of admission. …

333-505-0055 Discharge Planning Requirements (1) As used in this rule: (a) For purposes of subsection (2)(a) of this rule "lay caregiver" means an individual who, at the request of a patient, agrees to provide aftercare to the patient in the patient’s residence. (b) For purposes …

333-505-0060 Quality Assessment and Performance Improvement (1) The governing body of a hospital must ensure that there is an effective, written, facility-wide quality assessment and performance improvement program to evaluate and monitor the quality and appropriateness of patien…

333-505-0070 Infection Control and Prevention (1) A hospital shall establish and maintain an active facility-wide program for the control and prevention of infection. This program shall, at a minimum, include the following: (a) Identification of existing or potential infections i…

333-505-0075 HIV Post-Exposure Prophylaxis (1) Effective January 1, 2024, a hospital must adopt, maintain, and implement a policy for the dispensing of human immunodeficiency virus (HIV) post-exposure prophylaxis or therapies to a patient for occupational or nonoccupational expos…

333-505-0090 Request for Tissues and Organs (1) A hospital administrator or his or her designee shall contact the appropriate organ or tissue procurement organization when a patient dies at the hospital or when a patient's death is imminent. (2) After consultation with an organ o…

333-505-0100 Training for Requestors (1) All persons making requests for donations of organs, tissues, and eyes shall have received hospital-provided or procurement organization-provided training in accordance with this rule. (2) Training for requestors shall include but is not l…

333-505-0110 Hospital Compliance (1) A hospital shall demonstrate compliance with OAR 333-505-0090 and 333-505-0100 by maintaining a file, available for Oregon Health Authority review, including the following: (a) Training curriculum; (b) Hospital policy and procedure regarding r…

333-505-0120 Emergency Contraception (1) A hospital providing care to a female victim of sexual assault shall: (a) Promptly provide the victim with unbiased, medically and factually accurate written and oral information about emergency contraception; (b) Promptly orally inform th…

333-510-0001 Applicability These rules apply to all hospitals, regardless of classification. Statutory/Other Authority: ORS 413.042 & 441.055 Statutes/Other Implemented: ORS 441.055 & 442.015 History: PH 11-2009, f. & cert. ef. 10-1-09 HD 21-1993, f. & cert. ef. 10-28-93

333-510-0002 Definitions As used in OAR chapter 333, division 510, the following definitions apply: (1) "Hospital" means a hospital as described in ORS 442.015 and an acute inpatient care facility as defined in ORS 442.470. (2) "Nurse manager" means a registered nurse who has adm…

333-510-0010 Patient Admission and Treatment Orders (1) No patient, including patients admitted for observation status, shall be admitted to a hospital except on the order of an individual who has admitting privileges. The admitting physician, physician associate or nurse practit…

333-510-0020 Nursing Care Management (1) The nursing care of each patient, including patients admitted for observation status, in a hospital shall be the responsibility of a registered nurse (RN). (2) The RN will only provide services to the patients for which the RN is education…

333-510-0030 Nursing Services (1) The hospital shall provide a nursing service department, which provides 24-hour onsite registered nursing care, 7 days per week. (2) The nursing services department shall be under the direction of a nurse executive who is a registered nurse, lice…

333-510-0040 Nurse Executive (1) The nurse executive position shall be full-time (40 hours per week). Time spent in professional association workshops, seminars and continuing education may be counted as duties in considering whether or not the nurse executive is full-time. If th…

333-510-0045 Posting Requirements A hospital shall post an anti-retaliation notice on the premises that: (1) Summarizes the provisions of ORS 441.181, 441.183, 441.184 and 441.192; (2) Is clearly visible; and (3) Is posted where notices to employees and applicants for employment …

333-510-0050 Inservice Training Requirements for Nursing (1) The nurse executive or her or his designee shall coordinate all inservice training for nursing. Each year the inservice training agenda shall include at least the following: (a) Infection control measures; (b) Emergency…

333-510-0060 Patient Environment (1) A hospital shall provide for each patient: (a) A good bed, mattress, pillow with protective coverage, and necessary bed coverings; (b) Items needed for personal care; and (c) Separate storage space for clothing, toilet articles, and other pers…

333-515-0001 Applicability These rules apply to all hospitals, regardless of classification. Statutory/Other Authority: ORS 441.055 Statutes/Other Implemented: ORS 441.055 & 442.015 History: PH 11-2009, f. & cert. ef. 10-1-09 HD 21-1993, f. & cert. ef. 10-28-93

333-515-0005 Sterilization of Instruments, Equipment and Supplies (1) After the discharge of any patient, the bed, bed furnishings, bedside furniture, bed pans, urinals, wash basins, denture cups, drinking glasses, or any similar utensil or piece of equipment used by a patient sh…

333-515-0020 Sanitary Precautions (1) Provision shall be made for the proper cleaning of linen and other washable goods and proper disposal of all refuse. (2) All garbage and refuse shall be stored and disposed of in a manner that will not create a nuisance or a public health haz…

333-515-0030 Safety and Emergency Precautions (1) A hospital shall: (a) Have a physical plant and overall hospital environment that is developed and maintained in such a manner that the safety and well-being of patients are provided for. (b) Have telephone or another communicatio…

333-515-0040 Smoking Prohibition (1) The administrator or person in charge of the hospital may not permit a person to smoke tobacco: (a) In the hospital; or (b) Within 10 feet of a doorway, open window or ventilation intake of the hospital. (2) A hospital shall comply with ORS 43…

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 comp…