| (a) Upon initial triage, a facility shall provide each
patient and applicable legally authorized representative with a written
statement identifying the Texas Health and Human Services Commission
(HHSC) as the agency responsible for investigating complaints against
the facility.
(1) The statement shall inform persons that they may
direct a complaint to HHSC Complaint and Incident Intake (CII) and
include current CII contact information, as specified by HHSC.
(2) The facility shall prominently and conspicuously
post this statement in patient common areas and in visitor's areas
and waiting rooms so that it is readily visible to patients, employees,
and visitors. The information shall be in English and in a second
language appropriate to the demographic makeup of the community served.
(b) HHSC evaluates all complaints. A complaint must
be submitted using HHSC's current CII contact information for that
purpose, as described in subsection (a) of this section.
(c) HHSC documents, evaluates, and prioritizes complaints
based on the seriousness of the alleged violation and the level of
risk to patients, personnel, and the public.
(1) Allegations determined to be within HHSC's regulatory
jurisdiction relating to freestanding emergency medical care facilities
may be investigated under this chapter.
(2) HHSC may refer complaints outside HHSC's jurisdiction
to an appropriate agency, as applicable.
(d) HHSC shall conduct investigations to evaluate a
facility's compliance following a complaint of abuse, neglect, or
exploitation; or a complaint related to the health and safety of patients.
(e) HHSC may conduct an unannounced, on-site investigation
of a facility at any reasonable time, including when treatment services
are provided, to inspect or investigate:
(1) a facility's compliance with any applicable statute
or rule;
(2) a facility's plan of correction;
(3) a facility's compliance with an order of the executive
commissioner or the executive commissioner's designee;
(4) a facility's compliance with a court order granting
injunctive relief; or
(5) for other purposes relating to regulation of the
facility.
(f) An applicant or licensee, by applying for or holding
a license, consents to entry and investigation of any of its facilities
by HHSC.
(g) A facility shall cooperate with any HHSC investigation
and shall permit HHSC to examine the facility's grounds, buildings,
books, records, and other documents and information maintained by,
or on behalf of, the facility, unless prohibited by law.
(h) A facility shall permit HHSC access to interview
members of the governing body, personnel, and patients, including
the opportunity to request a written statement.
(i) HHSC shall maintain the confidentiality of facility
records as applicable under state and federal law.
(j) A facility shall permit HHSC to inspect and copy
any requested information, unless prohibited by law. If it is necessary
for HHSC to remove documents or other records from the facility, HHSC
provides a written description of the information being removed and
when it is expected to be returned. HHSC makes a reasonable effort,
consistent with the circumstances, to return any records removed in
a timely manner.
(k) Upon entry, the HHSC representative holds an entrance
conference with the facility's designated representative to explain
the nature, scope, and estimated duration of the investigation.
(l) The HHSC representative holds an exit conference
with the facility representative to inform the facility representative
of any preliminary findings of the investigation. The facility may
provide any final documentation regarding compliance during the exit
conference.
(m) Once an investigation is complete, HHSC reviews
the evidence from the investigation to evaluate whether there is a
preponderance of evidence supporting the allegations contained in
the complaint.
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