OAR 333-071-0470: Patient Admission and Treatment Orders

(1) No patient shall be admitted to a special inpatient care facility (SICF) except on the order of an individual who has admitting privileges. The admitting medical staff member for the facility shall provide sufficient information at the time of admission to establish that care can be provided to meet the needs of the patient. Admission medical information shall include a statement concerning the admitting diagnosis and general condition of the patient. Other pertinent medical information, orders for medication, diet, and treatments shall also be provided, as well as a medical history and physical. (2) Within 24 hours of a patient’s admission, an SICF shall ensure that: (a) The patient’s medical history is taken and a physical examination performed, unless: (A) A medical history and physical examination has been completed within 30 days prior to admission, as provided in the medical staff rules and regulations; or (B) The patient is readmitted within a month’s time for the same or related condition, as long as an interval note is completed; and (b) The patient is given a provisional diagnosis. (3) Even if a medical history or physical examination at the time of admission is not required under section (2) of this rule, an SICF shall ensure that any changes crucial to patient care are noted in an admission note. (4) Visits from licensed health care providers shall be according to patient's needs. Initial and ongoing assessments shall be performed for each patient and the results and observations recorded in the medical record. (5) A physician, physician associate or nurse practitioner with admitting privileges shall be responsible, as permitted by the individual's scope of practice for the care of any medical problem that may be present on admission or that may arise during an inpatient stay. (6) No medication or treatment shall be given except on the order of one duly authorized to give such orders within the State of Oregon. (7) Notwithstanding the requirements specified in sections (1) through (6) of this rule: (a) An SICF classified as a rehabilitation hospital shall ensure that: (A) Rehabilitation services are provided to patients under the orders of a qualified and licensed health care practitioner who is responsible for the care of the patient, acting within his or her scope of practice and who is authorized by the medical staff to order the services in accordance with SICF licensing laws; (B) All orders shall be documented in the patient's medical record in accordance with OAR 333-071-0430; (C) Patient assessments are conducted on a regular basis in accordance with 42 CFR 412.606. Each patient shall be evaluated by a rehabilitation physician at time of admission and shall be supervised by a rehabilitation physician, as reflected in at least three face-to-face visits each week; and (D) Respiratory services comply with 42 CFR 582.57. (b) An SICF classified as a freestanding hospice facility shall comply with CMS conditions of participation, 42 CFR 418.