OAR 333-071-0400: Organization Policies

(1) A special inpatient care facility's (SICF's) internal organization shall be structured to include appropriate departments and services consistent with the needs of its defined community. (2) An SICF shall adopt and maintain clearly written definitions of its organization, authority, responsibility, relationships and scope of services offered. (3) An SICF shall adopt, maintain and follow written policies that include but are not limited to: (a) Patient admission and transfer policies that address: (A) Types of clinical conditions not acceptable for patient admission; (B) Constraints imposed by limitations of services, staff coverage or physical facilities. No patient shall be admitted to a bed in any room, other than one regularly designated as a bedroom or ward; (C) Emergency patient admissions; (D) Requirements for informed consent signed by the patient or legal representative of the patient for diagnostic and treatment procedures; such policies and procedures shall address informed consent of minors in accordance with provisions in ORS 109.640, 109.670, and 109.675; (E) Requirements for identifying persons responsible for obtaining informed consent and other appropriate disclosures and ensuring that the information provided is accurate and documented appropriately in accordance with these rules and ORS 441.098; and (F) A process for the internal transfer of patients from one level or type of care to another, if applicable; (b) Patient discharge planning and termination of services in accordance with OAR 333-505-0055; (c) Patient rights; (d) Housekeeping; (e) All patient care services provided by the facility; (f) Preventive maintenance program for all aspects of the facility's physical plant, operations, and equipment used in patient care and patient environment; (g) Treatment or referral of acute sexual assault patients in accordance with ORS 147.403; (h) Identification of patients who could benefit from palliative care in order to provide information and facilitate access to appropriate palliative care in accordance with ORS 413.273; (i) Procedures for ensuring that an SICF provides health care interpreter services to a patient who prefers to communicate in a language other than English in accordance with ORS 413.559 and OAR 950-050-0160; (j) In accordance with OAR 333-071-0425, protocols and procedures for implementing and using potential threats of violence and disruptive behavior flagging systems. These protocols and procedures must be reviewed on an annual basis; and (k) For an SICF classified as a freestanding hospice facility, personnel safety program requirements in accordance with OAR 333-071-0423. These requirements must be reviewed on an annual basis. (4) In addition to the policies described in section (3) of this rule, an SICF shall, in accordance with the Patient Self-Determination Act, 42 CFR 489.102, adopt policies and procedures that require (applicable to all capable individuals 18 years of age or older who are receiving health care in the facility): (a) Providing to each adult patient, including emancipated minors, not later than five days after an individual is admitted as an inpatient, but in any event before discharge, the following in written form, without recommendation: (A) Information on the rights of the individual under Oregon law to make health care decisions, including the right to accept or refuse medical treatment and the right to execute directives and powers of attorney for health care; (B) Information on the policies of the facility with respect to the implementation of the rights of the individual under Oregon law to make health care decisions; (C) A copy of the advance directive form set forth in ORS 127.529; (D) The name of a person who can provide additional information concerning the forms for directives; (b) Documenting in a prominent place in the individual's medical record whether the individual has executed a directive; (c) Compliance with ORS chapter 127 relating to directives for health care; and (d) Educating the staff and the community on issues relating to directives. (5) An SICF's transfer agreements or contracts shall clearly delineate the responsibilities of parties involved. (6) Patient care policies shall be evaluated triennially and rewritten as needed, and presented to the governing body or a designated administrative body for approval triennially. Documentation of the evaluation is required. (7) An SICF shall have a system, described in writing, for the periodic evaluation of programs and services, including contracted services.