Revision 09-1


§90.191 Procedural Requirements


(a) Texas Department of Human Services (DHS) inspection and survey personnel must 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 licens

(b) An inspection must be conducted by an individual qualified surveyor or by a team, of which one member is a specialized staff person who has expertise in developmental disabilities.

(c) 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.

(d) Generally, all inspections, surveys, complaint investigations and other visits, whether routine or non-routine, 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.

(e) Certain visits may be announced, including, but not limited to, consultation visits to determine how a physical plant may be expanded or upgraded and visits to determine the progress of physical plant construction or repairs, equipment installation or repairs, or systems installation or repairs, or conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.

(f) Persons authorized to receive advance information on unannounced inspections include:

(1) citizen advocates invited to attend inspections, as described in subsection (g) of this section;

(2) representatives of the United States Department of Health and Human Services whose programs relate to the Medicare/Medicaid Long Term Care Program; and

(3) representatives of DHS whose programs relate to the Medicare/Medicaid long term care program.

(g) DHS will conduct at least two unannounced inspections each licensing period for each institution licensed under Health and Safety Code, Chapter 252, except as provided for in this subsection.

(1) A sufficient number of inspections will be conducted between the hours of 5:00 p.m. and 8:00 a.m. In randomly selected institutions, a cursory after-hours inspection will be conducted to verify staffing, assurance of emergency egress, resident care, medication security, food service or nourishments, sanitation, and other items as deemed appropriate. To the greatest extent feasible, any disruption of the residents will be minimal.

(2) For at least two unannounced inspections each licensing period, DHS may invite to the inspections at least one person as a citizen advocate who has an interest in or who is employed by or affiliated with an organization or agency that represents or advocates for persons with mental retardation or a related condition. DHS will provide to these organizations basic licensing information and requirements for the organizations' dissemination to their members whom they engage to attend the inspections. Advocates participating in the inspections must follow all DHS protocols. Advocates must provide their own transportation. The schedule of inspections in this category will be arranged confidentially in advance with the organizations. Participation by the advocates is not a condition precedent to conducting the inspection.

(h) The facility must make all of its 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) Examples of records and documents which may be requested and photocopied or otherwise reproduced are resident medical records, including nursing notes, pharmacy records medication records, and physician's orders.

(3) When the facility is requested to furnish the copies, the facility may charge DHS at a rate not to exceed the rate charged by DHS for copies. The procedure of copying is the responsibility of the administrator or his designee. If copying requires 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) DHS protects the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and DHS policy.

(5) Falsification of information contained in client records is prohibited.

(i) DHS will provide for a special team to conduct validation surveys or verify findings of previous licensure surveys.

(1) At DHS's discretion, based on record review, random sample, or any other determination, DHS may assign a team to conduct a validation survey. DHS may use the information to verify previous determinations or identify training needs to assure consistency in deficiencies cited and in punitive actions recommended throughout the state.

(2) Facilities are required to correct any additional deficiencies cited by the validation team but are not subject to any new or additional punitive action.

(j) During investigation and/or survey inspections, interviews of individuals residing in the facility or staff employed by the facility may be conducted in private without fear of retaliation toward staff or residents.

(k) Facility staff must be available at the facility within 45 minutes of telephone contact by survey staff.


§90.192 Determinations and Actions Pursuant to Inspections, Surveys, or Investigations


(a) DADS will determine if a facility meets licensure requirements through inspections, surveys, and investigations.

(b) During an investigation resulting from a complaint, DADS does not disclose the source of the complaint.

(c) At the conclusion of an inspection, survey, or investigation, a representative of DADS holds an exit conference with a representative of the facility and provides the facility representative a written list of violations./p>

(d) If DADS cites an additional violation during a review of field notes or preparation of the official final list of violations, DADS:

(1) communicates the additional violation to the facility in writing within ten working days after the exit conference; and

(2) gives the facility an additional face-to-face exit conference regarding the additional violations.

(e) DADS provides the facility with a clear and concise summary in nontechnical language of each licensure inspection or complaint investigation.

(f) The facility must submit a plan to correct cited violations to the regional director of the area in which the facility is located no later than 10 working days after the date the facility receives the final, official statement of violations. To be accepted by DADS, a plan to correct violations must state when the corrective action will be completed and must address:

(1) how the facility will accomplish corrective action for residents directly affected by the cited violation;

(2) how the facility will identify other residents who may be affected by the cited violation; and

(3) how the facility will avoid having the violation recur.

(g) If a facility fails to submit a plan to correct violations that meets the requirements of subsection (f) of this section, DADS may assess an administrative penalty against the facility in accordance with §90.236(a)(7) of this chapter (relating to Administrative Penalties).