Revision 09-1



§98.81 Procedural Requirements


(a) DADS may enter the premises of a facility at reasonable times and make an inspection necessary to issue a license or renew a license. DADS inspection and survey personnel will perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits as required for carrying out the responsibilities of licensing.

(b) An inspection may be conducted by a surveyor.

(c) Generally, all inspections, surveys, complaint investigations and other visits, whether routine or nonroutine, made for the purpose of determining the appropriateness of client care and day-to-day operations of a facility will be unannounced. Any exceptions must be justified.

(d) Certain visits may be announced, including initial architectural inspections, visits to determine the progress of physical plant construction or repairs, equipment installation or repairs, systems installation or repairs, or conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.

(e) Any person may request an inspection of a facility by notifying DADS in writing of an alleged violation of a licensing requirement. The complaint shall be as detailed as possible and signed by the complainant. DADS performs an on-site inspection as soon as feasible but no later than 30 days after receiving the complaint, unless after an investigation the complaint is found to be frivolous. DADS will respond to the complainant in writing.

(f) ADS will receive and investigate anonymous complaints.

(g) The facility must make all of its books, records, and other documents maintained by or on behalf of a facility accessible to DADS upon request.

(1) DADS is authorized to photocopy documents, photograph clients, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection, survey, or investigation that DADS reasonably believes threaten the health and safety of a client.

(2) Examples of records and documents that may be requested and photocopied or otherwise reproduced are client medical records, including nursing notes, pharmacy records, medication records, and physician's orders.

(3)The facility may charge DADS at a rate not to exceed the rate DADS charges for copies. The procedure of copying is the responsibility of the director or his designee. If copying requires that the records be removed from the facility, a representative of the facility is expected to accompany the records and assure their order and preservation.

(4)DADS protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and DADS policy.

(h)The source of the complaint is not revealed.


§98.82 Determinations and Actions Pursuant to Inspections


(a) DADS determines if a facility meets the licensing rules, including both physical plant and facility operation requirements.

(b)Violations of regulations are listed on forms designed for the purpose of the inspection.

(c) At the conclusion of an inspection or survey, the violations are discussed in an exit conference with the facility's management. A written list of the violations is left with the facility at the time of the exit conference.

(d) If, after the initial exit conference, additional violation are cited, the violations are communicated to the facility within 10 working days after the initial exit conference.

(e) DADS provides a clear and concise summary in nontechnical language of each licensure inspection, inspection of care, and complaint investigation, if applicable. The summary outlines significant violations noted at the time of the inspection or survey, but does not include names of clients, staff, or any other information that would identify individual clients or other prohibited information under general rules of public disclosure. The summary is provided to the facility at the time the report of contact or similar document is provided.

(f) Upon receipt of the final statement of violations, the facility has 10 working days to submit an acceptable plan of correction to the DADS Regulatory Services regional director. An acceptable plan of correction must address the following:

(1) how the facility will accomplish the corrective action for those clients affected by each violation;

(2) how the facility will identify other clients with the potential to be affected by the same violation;

(3) how the facility will put the corrective measure into practice or make systemic changes to ensure that the violation does not recur;

(4) how the facility will monitor the corrective action to ensure that the violation is corrected and will not recur; and

(5) the date the corrective action will be completed.

(g) If the provider and the inspector cannot resolve a dispute regarding a violation of regulations, the provider is entitled to an informal dispute resolution (IDR) at the regional level for all violations. For a violation that resulted in an adverse action, the provider is entitled to an IDR at either the regional or state office level.

(1) A written request and all supporting documentation must be submitted to the Regional Director, Regulatory Services, for a regional IDR; or to Regulatory Services, Texas Department of Aging and Disability Services, P.O. Box 149030, E-351, Austin, Texas 78714-9030, for a central office IDR, no later than the tenth day after receipt of the official statement of violations.

(2) DADS completes the IDR process no later than the 30th day after receipt of a request from a facility.

(3) Violations deemed invalid in an IDR will be so noted in DADS' records.


§98.83 Referrals to the Attorney General


DADS may refer a facility to the attorney general who may petition a district court for:

(1) a temporary restraining order to restrain a person from a violation or threatened violation of the requirements or any other law affecting clients if DADS reasonably believes that the violation or threatened violation creates an immediate threat to the health and safety of a client; and

(2) an injunction to restrain a person from a violation or threatened violation of the requirements or any other law affecting clients if DADS reasonably believes that the violation or threatened violation creates a threat to the health and safety of a client.


§98.84 Procedures for Inspection of Public Records


(a) Procedures for inspection of public records will be in accordance with the Texas Government Code, Chapter 552 and as further described in this section.

(b) DADS' Regulatory Services Division is responsible for the maintenance and release of records on licensed facilities, and other related records.

(c) The application for inspection of public records is subject to the following criteria.

(1) The application must be made to Regulatory Services, Texas Department of Aging and Disability Services, Mail Code E-349, P.O. Box 149030, Austin, Texas 78714-9030.

(2) The requester must identify himself.

(3) The requester must give reasonable prior notice of the time for inspection and/or copying of records.

(4) The requester must specify the records requested.

(5) On written applications, if DADS is unable to ascertain the records being requested, DADS may return the written application to the requester for clarification.

(6) DADS will provide the requested records as soon as possible; however, if the records are in active use, or in storage, or time is needed for proper de-identification or preparation of the records for inspection, DADS will so advise the requester and set an hour and date within a reasonable time when the records will be available.

(d) Original records may be inspected or copied, but in no instance will original records be removed from DADS offices.

(e) Regulatory Services will charge for copies of records upon request.

(1) If the requester simply wants to inspect records, the requester will specify the records to be inspected. DADS will make no charge for this service, unless the director of Regulatory Services determines a charge is appropriate based on the nature of the request.

(2) If the requester wants copies of a record, the requester will specify in writing the records to be copied on an appropriate DADS form, and DADS will complete the form by specifying the cost of the records, which the requester must pay in advance. Checks and other instruments of payment must be made payable to the Department of Aging and Disability Services.

(3) Any expenses for standard-size copies incurred in the reproduction, preparation, or retrieval of records must be borne by the requester on a cost basis in accordance with costs established by the Office of the Attorney General or DADS for office machine copies.

(4) For documents that are mailed, DADS will charge for the postage at the time it charges for the production. All applicable sales taxes will be added to the cost of copying records.

(5) When a request involves more than one long-term care facility, each facility will be considered a separate request.