Revision 14-2

 

§92.81 Inspections and Surveys

  1. Texas Department of Human Services (DHS) inspection and survey personnel will perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits from time to time as they deem appropriate or as required for carrying out the responsibilities of licensing.
  2. An inspection may be conducted by an individual surveyor or by a team, depending on the purpose of the inspection or survey, size of facility, and service provided by the facility, and other factors.
  3. To determine standard compliance which cannot be verified during regular working hours, night or weekend inspections may be conducted to cover specific segments of operation and will be completed with the least possible interference to staff and residents.
  4. Generally, all inspections, surveys, complaint investigations and other visits, whether routine or nonroutine, made for the purpose of determining the appropriateness of resident care and day-to-day operations of a facility will be unannounced; any exceptions must be justified.
  5. Certain visits may be announced, including, but not limited to, visits to determine conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.
  6. The facility must make all books, records, and other documents maintained by or on behalf of a facility accessible to DHS upon request.
    1. DHS is authorized to photocopy documents, photograph residents, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection, survey, or investigation that DHS reasonably believes threaten the health and safety of a resident.
    2. Records and documents which may be requested and photocopied or otherwise reproduced include, but are not limited to, admission sheets, medication profiles, observation notes, medication refusal notes, and menu records.
    3. When the facility is requested to furnish the copies, the facility may charge DHS at the rate not to exceed the rate charged by DHS for copies. Collection must be by billing DHS. The procedure of copying is the responsibility of the administrator or his designee. If copying requires removal of the records from the facility, a representative of the facility will be expected to accompany the records and assure their order and preservation.
    4. DHS will protect the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and DHS policy.

 

§92.82 Determinations and Actions

  1. DADS determines if a facility meets DADS licensing rules, including physical plant and facility operation requirements, by conducting inspections, surveys, investigations, and on-site visits.
  2. DADS lists violations of licensing rules on a report of contact. The report of contact includes a specific reference to a licensing rule that has been violated.
  3. At the conclusion of an inspection, survey, investigation, or on-site visit, a DADS surveyor conducts an exit conference to advise the facility of the findings resulting from the inspection, survey, investigation, or on-site visit.
  4. At the exit conference, the surveyor provides a copy of the report of contact described in subsection (b) of this section to the facility.
  5. If, after the initial exit conference, a DADS surveyor cites an additional licensing rule violation, the surveyor conducts another exit conference regarding the newly identified violations, and updates the report of contact with a specific reference to the licensing rule that has been violated.
  6. DADS provides to the facility a written statement of violations from an inspection, survey, investigation, or on-site visit on DADS Form 3724 within 10 days after the final exit conference. The statement of violations includes a clear and concise summary in nontechnical language of each licensing rule violation. The statement of violations does not include names of residents or staff, statements that identify a resident, or other prohibited information.
  7. A facility must submit an acceptable plan of correction to the DADS regional director within 10 days after receiving the statement of violations described in subsection (f) of this section. An acceptable plan of correction must address:
    1. how corrective action will be accomplished for a resident affected by a violation of a licensing rule;
    2. how the facility will identify other residents who may be affected by the violation of the licensing rule;
    3. how the corrective action the facility implements will ensure the violation does not reoccur;
    4. how the facility will monitor its corrective action to ensure the violation is being corrected and will not reoccur; and
    5. dates when corrective action will be completed.

 

§92.83 Informal Dispute Resolution

  1. If a facility and DADS cannot resolve a dispute regarding a violation of a licensing rule, the facility is entitled to an informal dispute resolution (IDR) conducted by the Texas Health and Human Services Commission (HHSC) in accordance with Texas Health and Safety Code §247.051.
  2. Within 10 days after the facility receives the statement of violations described in §92.82(f) of this subchapter (relating to Determinations and Actions), the facility must submit a written request for an IDR using the form and in accordance with procedures on the HHSC website at www.hhsc.state.tx.us.