Revision 16-1

 

§15.1301 Inspections and Visits

 

(a) DADS performs inspections, follow-up visits, compliance investigations, investigations of abuse, neglect and exploitation, and other contact visits at a center as deemed appropriate or as required to determine a center's compliance with this chapter.

(b) An inspection may be conducted by an inspector or by a team depending on the purpose of the inspection, size of a center, and other factors.

(c) DADS does not announce inspections or visits.

(d) DADS conducts at least one unannounced licensing inspection annually after issuance of a license.

(e) DADS may visit a center for purposes other than the reasons described in subsection (a) of this section.

(1) DADS may visit a center to consult with a center's staff to determine how a center's physical space may be expanded or upgraded or determine the progress of a center's construction or repairs, equipment installation or repairs, systems installation or repairs, or when conditions or emergencies arise, including fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.

(2) DADS may announce visits that are not for a purpose described in subsection (a) of this section.

 

§15.1302 Investigation of Complaints and Self-Reported Incidents

 

(a) DADS investigates complaints of abuse, neglect, or exploitation if:

(1) the act occurs at the center;

(2) the center is responsible for the supervision of a minor at the time the act occurs;

(3) the alleged perpetrator is associated with the center; or

(4) the alleged perpetrator is present at the center.

(b) DADS refers complaints of abuse, neglect, or exploitation not meeting the criteria in subsection (a) of this section to the Department of Family and Protective Services.

(c) DADS conducts an investigation under this section in accordance with THSC §260 A.007.

(d) A center's investigation of complaints and self-reported incidents does not preclude DADS from taking action in accordance with Subchapter G of this chapter (relating to Enforcement).

(e) DADS notifies the following individuals of the results of a DADS investigation:

(1) the individual who reported the allegation or complaint;

(2) an adult minor;

(3) a minor's parent;

(4) any person designated by an adult minor or minor's parent to receive information concerning a minor; and

(5) a center.

 

§15.1303 Cooperation with an Inspection and Visit

 

(a) By applying for and holding a license, a license holder consents to entry or inspection of the center's premises by a DADS representative to verify compliance with THSC Chapter 248A and this chapter.

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

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

(2) DADS may request, photocopy, and otherwise reproduce records and documents including admission sheets, medication records, observation notes, medical records, clinical notes, and any other of a center's documents.

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

(c) During an inspection or investigation, a center's representative and staff must not:

(1) make a false statement that a person knows or should know is false of a material fact about a matter under investigation by DADS;

(2) willfully interfere with the work of a DADS representative;

(3) willfully interfere with a DADS representative in preserving evidence of a violation; or

(4) refuse to allow a DADS representative to inspect a book, record, or file required to be maintained by or on behalf of a center.

(d) DADS may assess an administrative penalty for a violation of provisions in this section, or may take other enforcement action to deny, revoke, or suspend a license, if a center does not cooperate with an inspection.

 

§15.1304 Staff Requirements for an Inspection

 

(a) The center's administrator, alternate administrator, nursing director, or alternate nursing director must be present in person at the entrance and exit conferences of every DADS inspection or visit and be available in person during the inspection.

(b) If a required individual is not at the center when the inspector arrives and is unavailable during the inspection, the inspector will make reasonable attempts to contact the individual.

(c) If an inspector arrives during regular business hours and the center is closed, an administrator, alternate administrator, nursing director, or alternate nursing director must provide the inspector entry to the center no later than two hours after the inspector's arrival at the center. The center must comply with the notice requirements described in §15.201 of this chapter (relating to Operating Hours).

 

§15.1305 General Provisions

 

(a) DADS determines if a center meets the requirements of the THSC Chapter 248A and this chapter.

(b) After an inspection is completed, the inspector holds an exit conference to inform a center of the preliminary findings.

(c) A center may submit additional written documentation and facts after the exit conference only if a center describes the additional documentation and facts to the inspector during the exit conference.

(1) A center must submit the additional written documentation and facts to the DADS inspector or inspection team no later than two business days after the end of the exit conference.

(2) If a center properly submits additional written documentation, the inspector may add the documentation to the record of the inspection.

(d) DADS provides a written notification of the inspection results to the center no later than 10 business days after the exit conference. The written notification includes a statement of violations and instructions for submitting an acceptable plan of correction, and provides an opportunity for an informal dispute resolution.

(e) If a center receives DADS written notification of the inspection results indicating that the center is in violation of THSC Chapter 248A or this chapter, the center must follow DADS instructions included with the notification for submitting an acceptable plan of correction.

(f) f required, a center must submit an acceptable plan of correction that includes the corrective measures and time frame in which the center will comply to ensure correction of a violation. If a center fails to correct each violation by the date on the plan of correction, DADS may take enforcement action against the center.

(g) A center must submit an acceptable plan of correction for each violation no later than 10 calendar days after receipt of DADS written notification of the inspection results. An acceptable plan of correction must address:

(1) how the center will accomplish corrective action for the minors affected by the violation;

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

(3) the measures that the center will incorporate, or systemic changes the center made to ensure the violation will not recur;

(4) how the center will monitor its corrective actions to ensure that the violation is corrected and will not recur; and

(5) dates when the center's corrective action will be completed.

(h) A center's acceptable plan of correction does not preclude DADS from taking enforcement action against the center in accordance with Subchapter G of this chapter (relating to Enforcement).

(i) A center must submit a plan of correction in response to DADS written notification of inspection results that specifies a violation even if the center disagrees with the inspection results.

(j) If a center disagrees with the inspection results, the center may request an informal dispute resolution (IDR). The center must submit a written request and all supporting documentation DADS no later than the 10th calendar day after the center receives DADS statement of violations.

(k) A center waives its right to an IDR if the center fails to submit the required information to DADS Regulatory Services, Survey and Certification Enforcement Unit, within the required time frames.

(l) A center must make available to any person on request a copy of each DADS inspection report. Before making an inspection report available under this subsection, the center must redact from the report any information that is confidential under other law.

(m) A center must post inspection results in a conspicuous location at the center.