OAR 333-071-0360: Governing Body Responsibility

(1) If a special inpatient care facility (SICF) is part of a multi-hospital system, one governing body may oversee multiple licensed hospitals within the system. (2) The governing body of each SICF shall be responsible for the operation of the facility, the selection of the medical staff and the quality of care rendered in the facility. The governing body shall ensure that: (a) All health care personnel for whom state licenses or registrations are required are currently licensed or registered; (b) Qualified individuals allowed to practice in the SICF are credentialed and granted privileges consistent with their individual training, experience and other qualifications; (c) Procedures for granting, restricting and terminating privileges exist and that such procedures are regularly reviewed to assure their conformity to applicable law; (d) It has an organized medical staff responsible for reviewing the professional practices of the SICF for the purposes of improving patient safety and patient care; (e) A physician is not denied medical staff privileges at the facility solely on the basis that the physician holds medical staff membership or privileges at another health care facility; (f) All SICF employees and health care practitioners granted privileges have been tested for tuberculosis in accordance with OAR 333-071-0450; and (g) A notice, in a form specified by the Oregon Health Authority, summarizing the provisions of ORS 441.152 through 441.177 is clearly visible to the public that includes a phone number for purposes of reporting a violation of nurse staffing laws. (3) An SICF may grant privileges to nurse practitioners or physician associates in accordance with ORS 441.064 and subject to SICF rules governing credentialing and staff privileges. (4) An SICF shall require that every patient admitted shall be and remain under the care of a member of the medical staff as specified under the medical staff by-laws. (5) Nothing in these rules shall preclude an attending physician, identified by a patient, from providing care to the patient in a freestanding hospice facility.