| (a) The department may conduct an inspection of each facility before issuing an initial license or a renewal of a facility license. (b) Complaint investigations. (1) Complaint investigations are conducted if the department finds that reasonable cause exists to believe that the facility has violated provisions of the Act, this chapter, special license conditions, or orders of the commissioner of state health services. (2) Complaints received by the department concerning abuse and neglect, or illegal, unprofessional, or unethical conduct will be conducted in accordance with §131.60 of this title (relating to Abuse and Neglect). (3) Complaint investigations are unannounced. (4) Following the investigation of a complaint, the department shall notify the complainant if the complaint was substantiated and if regulatory violations were identified or if no violations were found. (c) Re-inspection. (1) The department may conduct re-inspection if a facility applies for the reissuance of its license after the suspension or revocation of the facility's license, the assessment of administrative or civil penalties, or the issuance of an injunction against the facility for violations of the Act, this chapter, a special license condition, or an order of the commissioner. (2) A re-inspection may be conducted to ascertain compliance with either health or construction requirements or both. (d) General. (1) The department may make any inspection, survey, or investigation that it considers necessary. A representative of the department may enter the premises of a facility at any reasonable time to make an inspection or an investigation to ensure compliance with or prevent a violation of the Act, the rules adopted under the Act, an order or special order of the commissioner, a special license provision, a court order granting injunctive relief, or other enforcement procedures. Ensuring compliance includes permitting photocopying of any records or other information by or on behalf of the department as necessary to determine or verify compliance with the Act or rules adopted under the Act, except that the department may not photocopy, reproduce, remove or dictate from any part of the root cause analysis or action plan required under §131.63 of this title (relating to Patient Safety Program). (2) The department or a representative of the department is entitled to access to all books, records, or other documents maintained by or on behalf of the facility to the extent necessary to enforce the Act, this chapter, an order or special order of the commissioner, a special license provision, a court order granting injunctive relief, or other enforcement procedures. The department shall maintain the confidentiality of facility records as applicable under federal or state law. (3) By applying for or holding a facility license, the facility consents to entry and inspection or investigation of the facility by the department or a representative of the department in accordance with the Act and this chapter. (e) Inspection and investigation protocol. (1) The department surveyor(s) shall hold a conference with the facility administrator or designee before beginning the on-site inspection or investigation to explain the nature, scope, and estimated time schedule of the inspection or investigation. (2) Department surveyor(s) may conduct interviews with any person with knowledge of the facts. (3) The department surveyor(s) shall inform the facility administrator or designee of the preliminary findings of the inspection or investigation and shall give the person a reasonable opportunity to submit additional facts or other information to the department's authorized representative in response to those findings. (4) Following an inspection or investigation of a facility by the department, the department surveyor(s) shall hold an exit conference with the facility administrator or designee and other invited staff and provide the following to the facility administrator or designee: (A) the specific nature of the inspection or investigation; (B) any alleged violations of a specific statute or rule; (C) identity of any records that were duplicated; (D) the specific nature of any finding regarding an alleged violation or deficiency; (E) if the deficiency is alleged, the severity of the deficiency; and (F) if there are no deficiencies found, a statement indicating this fact. (5) If deficiencies are cited, the facility must submit the plan of correction to the department surveyor not later than the 10th working day after the facility receives the statement of deficiencies. The plan of correction must specify the date by which correction will be made and any comments concerning the inspection or investigation. Additional facts, written comments, or other information the facility provides in response to the statement of deficiencies shall be made a part of the record of the inspection or investigation for all purposes. (6) The department surveyor(s) shall obtain the signature of the facility administrator or designee acknowledging the receipt of the statement of deficiencies and plan of correction form. (7) The department surveyor(s) shall inform the administrator or designee of the facility's right to an informal administrative review when there is disagreement with the surveyor's findings and recommendations or when additional information bearing on the findings is available. (8) If the department does not accept the plan of correction, the department shall notify the facility in writing. The facility shall resubmit a revised plan of correction not later than the 10th working day after the facility receives the department's written notice. After the department receives an acceptable plan of correction, the department shall send the facility written notice acknowledging that the department has received an acceptable plan of correction. (9) The facility may respond to the department by facsimile. (10) The facility shall come into compliance by the completion date provided on the statement of deficiencies and plan of correction form. (11) The department shall verify the correction of deficiencies either by mail or by an on-site inspection or investigation. (12) Acceptance of a plan of correction does not preclude the department from taking enforcement action under §131.101 of this title (relating to Enforcement Actions). (f) Release of information by the department. (1) Upon written request, the department shall provide information on the identity, including the signature, of each department representative conducting, reviewing, or approving the results of the inspection or investigation, and the date on which the department representative acted on the matter. (2) Upon written request, the department shall release inspection documents in accordance with state and federal law. |
