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, and the pharmacy quality assurance commission, 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.