| (a) Routine inspections. The department may conduct
an inspection of a facility prior to the issuance or renewal of a
license.
(b) Complaint investigations.
(1) Complaint investigations are unannounced and are
conducted to ensure compliance of the facility with the provisions
of Health and Safety Code (HSC), Chapter 248, this chapter, special
license conditions, or orders of the commissioner of health (commissioner).
(2) Complaints received by the department concerning
abuse, neglect, or exploitation will be investigated in accordance
with §125.33(c)(2) of this title (relating to Resident Rights).
(3) If an individual wishes to report an alleged violation
of the Act or this chapter, the individual shall notify the department
in persons, by telephone at (888) 973-0022, by facsimile or by writing
the department at Health Facility Licensing and Certification Division,
1100 West 49th Street, Austin, Texas 78756-3199, or electronic medium.
(c) General.
(1) The department may make any survey, inspection
or investigation that it considers necessary. A department representative(s)
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 HSC, Chapter 248, this chapter, 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 statute or rules adopted under the statute.
(2) The department representative(s) 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 HSC,
Chapter 248, 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 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 in accordance with HSC, Chapter 248,
and this chapter.
(d) Inspection and investigation protocol.
(1) The department representative(s) shall hold a conference
with the facility director 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) The department representative(s) may conduct interviews
with any person with knowledge of the facts.
(3) The department representative(s) shall inform the
facility director 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
representative in response to those findings.
(4) Following an inspection or investigation of a facility
by the department, the department representative(s) shall hold an
exit conference with the facility director or designee and other invited
staff and provide the following information:
(A) the nature of the inspection or investigation;
(B) an overview of the findings regarding alleged violations
or deficiencies identified by the department representative(s);
(C) identity of any records that were duplicated; and
(D) if there are no deficiencies found, a verbal statement
indicating this fact.
(5) If deficiencies are cited, the facility shall provide
a plan of correction (POC) to the department either at the time of
the exit conference or within 10 calendar days following the facility's
receipt of a statement of deficiencies (SOD).
(A) The POC shall include the facility's planned action
to correct the deficiency and the expected completion date. The POC
shall be specific and realistic, stating exactly how the deficiency
was or will be corrected. The director or their designee must sign
the POC.
(B) A facility may refute the accuracy of a cited deficiency
or survey finding.
(i) Objections may be recorded on the SOD form, however,
a POC is still required to be submitted; or
(ii) A facility may record an objection on the SOD
form and not submit a POC, however, the facility must submit a convincing
argument and documented evidence that the cited deficiency or survey
finding is invalid.
(iii) Should the department agree with the supporting
documentation, the cited deficiency or survey finding shall be deleted
from the SOD form.
(iv) Should the department sustain the cited deficiency,
the department will inform the facility in writing that a POC is required.
The facility shall submit a POC to the department within 10 calendar
days of the facility's receipt of the department's decision.
(6) The department representative(s) shall inform
the director or their designee of the facility's right to an informal
administrative review when there is disagreement with the representative's
findings and recommendations or when additional information bearing
on the findings is available.
(7) If the department determines that the POC is not
acceptable, the department shall notify the facility in writing that
it is responsible to provide the department an acceptable POC. The
facility shall submit the new POC within 10 calendar days of the facility's
receipt of the department's written notice.
(8) The facility shall come into compliance by the
completion date provided on the POC.
(9) The department may verify the correction of deficiencies
either in writing or by an on-site survey or investigation.
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