OAR 333-071-0290: Surveys

(1) The Authority shall, in addition to any investigations conducted under OAR 333-071-0280, conduct at least one on-site licensing survey of each SICF every three years to determine compliance with SICF licensing laws and at such other times as the Authority deems necessary. (2) In lieu of an on-site inspection required under section (1) of this rule, the Authority may accept: (a) CMS certification by a federal agency or an approved accrediting organization; or (b) A survey conducted within the previous three years by an accrediting organization approved by the Authority, if: (A) The certification or accreditation is recognized by the Authority as addressing the standards and condition of participation requirements of the CMS and other standards set by the Authority. An SICF must provide the Authority with the letter from CMS indicating its deemed status; (B) The SIFC notifies the Authority to participate in any exit interview conducted by the federal agency or accrediting body; and (C) The SIFC provides copies of all documentation concerning the certification or accreditation requested by the Authority. (3) An SICF shall permit Authority staff access to the facility during a survey. (4) A survey may include but is not limited to: (a) Interviews of patients, patient family members, SICF management and staff; (b) On-site observations of patients, staff performance, and the physical environment of the SICF; (c) Review of documents and records; and (d) Patient audits. (5) An SICF shall make all requested documents and records available to the surveyor for review and copying. (6) Following a survey, Authority staff may conduct an exit conference with the SICF administrator or the administrator's designee. During the exit conference Authority staff shall: (a) Inform the SICF representative of the preliminary findings of the inspection; and (b) Give the person a reasonable opportunity to submit additional facts or other information to the surveyor in response to those findings. (7) Following a survey, Authority staff shall prepare and provide the SICF administrator or the administrator's designee specific and timely written notice of the findings. (8) If the findings result in a referral to another regulatory agency, Authority staff shall submit the applicable information to that referral agency for its review and determination of appropriate action. (9) If no deficiencies are found during a survey, the Authority shall issue written findings to the SICF administrator indicating that fact. (10) If deficiencies are found, the Authority shall take informal or formal enforcement action in compliance with OAR 333-071-0315 or 333-071-0320.