WAC 246-320-016   Department responsibilities -- On-site survey and complaint investigation.  This section outlines the department's on-site survey and complaint investigation activities and roles.

     (1) Surveys. The department will:

     (a) Conduct on-site surveys of each hospital on average at least every eighteen months or more often using the health and safety standards in this chapter and chapter 70.41 RCW;

     (b) Coordinate the on-site survey with other agencies, including local fire jurisdictions, state fire marshal, state pharmacy board, and report the survey findings to those agencies;

     (c) Notify the hospital in writing of the survey findings following each on-site survey;

     (d) Require each hospital to submit a corrective action plan addressing each deficient practice identified in the survey findings;

     (e) Notify the hospital when the hospital submitted plan of correction adequately addresses the survey findings; and

     (f) Accept on-site surveys conducted by the Joint Commission or American Osteopathic Association as meeting the eighteen-month survey requirement in accordance with RCW 70.41.122.

     (2) Complaint investigations. The department will:

     (a) Conduct an investigation of every complaint against a hospital that concerns patient well being;

     (b) Notify the hospital in writing of state complaint investigation findings following each complaint investigation;

     (c) Require each hospital to submit a corrective action plan addressing each deficient practice identified in the complaint investigation findings; and

     (d) Notify the hospital when the hospital submitted plan of correction adequately addresses the complaint investigation findings.

     (3) The department may:

     (a) Direct a hospital on how to implement a corrective action plan based on the findings from an on-site survey or complaint investigation; or

     (b) Contact a hospital to discuss the findings of the Joint Commission or American Osteopathic Association on-site accreditation survey.



[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. 09-07-050, § 246-320-016, filed 3/11/09, effective 4/11/09.]