Oregon Health Authority
Public Health Division - Chapter 333
Division 501
HOSPITAL MONITORING, SURVEYS, INVESTIGATIONS, DISCIPLINE, AND CIVIL PENALTIES
333-501-0040
Nurse Staffing Complaint Investigation Procedures
(1) The Authority shall conduct an unannounced on-site investigation of a hospital within 60 calendar days after receiving a valid complaint against the hospital for violating a provision of ORS 441.152 to 441.177. A complaint is valid when an allegation, if assumed to be true, would violate a requirement of ORS 441.152 to 441.177.
(2) During an investigation, the Authority shall review any hospital record and conduct any interview or site visit that is necessary to determine whether the hospital has violated a provision of ORS 441.152 to 441.177.
(3) In conducting an investigation, the Authority may:
(a) Review any documentation that may be relevant to the complaint, including patient records; and
(b) Interview any person who may have information relevant to the complaint, including patients and family members.
(4) In reviewing information collected during an investigation, the Authority shall consider:
(a) The amount and strength of objective evidence, if any, that substantiates or refutes the complaint; and
(b) The number and credibility of witnesses, if any, who attest to or refute an alleged violation.
(5) Following an investigation, the Authority shall issue a written investigation report that communicates the results of the investigation no more than 30 business days after the investigation closes. This investigation report:
(a) Shall be issued to the hospital and both co-chairs of the hospital nurse staffing committee; and
(b) May include a notice of civil penalties that complies with ORS 441.175 and OAR 333-501-0045.
(6) If the investigation report identifies any area of noncompliance, the hospital shall submit a written plan to correct each identified deficiency. This plan:
(a) Shall be called the plan of correction;
(b) Shall be submitted no more than 30 business days after receiving the Authority’s investigation report; and
(c) Shall be evaluated by the Authority for sufficiency.
(7) No more than 30 business days after receipt of the hospital’s plan of correction, the Authority shall issue a written determination that communicates whether the plan of correction is sufficient. This determination:
(a) Shall be issued to the hospital and both co-chairs of the hospital nurse staffing committee; and
(b) Shall require the hospital to either:
(A) Revise and resubmit the rejected plan of correction no more than 30 business days after receiving the Authority’s determination that the plan is insufficient; or
(B) Implement the approved plan of correction no more than 45 business days after receiving the Authority’s determination that the plan is sufficient.
(8) Following the approval of the plan of correction, the Authority shall conduct a second investigation of the hospital to verify that the hospital has implemented the approved plan of correction. This investigation shall be conducted within 60 business days of the plan of correction approval date.
(9) The identity of an individual providing evidence during an investigation will be kept confidential to the extent permitted by law.
Statutory/Other Authority: ORS 413.042, 441.025, 441.044, 441.171 & 441.175
Statutes/Other Implemented: ORS 441.044 & 441.171
History:
PH 59-2023, temporary suspend filed 12/21/2023, effective 01/01/2024 through 06/28/2024
PH 10-2023, minor correction filed 02/07/2023, effective 02/07/2023
PH 22-2016, f. & cert. ef. 7-1-16
PH 26-2010, f. 12-14-10, cert. ef. 12-15-10
PH 11-2009, f. & cert. ef. 10-1-09