| (a) HHSC 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, any
violations are discussed in an exit conference with the facility's
management. HHSC leaves s written list of violations with the facility
at the time of the exit conference.
(d) If additional violations are cited after the initial
exit conference, the violations are communicated to the facility within
10 working days after the initial exit conference.
(e) HHSC provides a clear and concise written summary
in nontechnical language of each licensure inspection, inspection
of care, and complaint investigation. 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 HHSC Regulatory Services Regional Office director. An acceptable
plan of correction must address:
(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 facility disagrees with a survey finding
regarding a violation of regulations, the facility is entitled to
an informal dispute resolution (IDR) for the violation.
(1) The facility must request an IDR by submitting
all supporting documentation to HHSC Regulatory Enforcement no later
than the tenth day after receipt of the official statement of violations.
(2) HHSC completes the IDR process no later than the
30th day after receipt of a request from a facility.
(3) HHSC notifies the facility of the results of the
IDR process in writing, and violations deemed invalid in the IDR are
so noted in HHSC's records.
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