| (a) A limited services rural hospital (LSRH) shall
provide each patient and applicable consenter at the time of admission
with a written statement identifying the Texas Health and Human Services
Commission (HHSC) as the agency responsible for investigating complaints
against the LSRH.
(1) The statement shall inform persons that they may
direct a complaint to HHSC's Complaint and Incident Intake (CII) and
include current CII contact information, as specified by HHSC.
(2) The LSRH shall prominently and conspicuously post
this information in each patient common area, visitor area, and waiting
room 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 person must submit
a complaint using HHSC's current CII contact information for complaint
submission, 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) HHSC may investigate allegations determined to
be within HHSC's regulatory jurisdiction relating to LSRH's under
this chapter.
(2) HHSC may refer complaints outside HHSC's jurisdiction
to an appropriate agency, as applicable.
(d) HHSC shall conduct an investigation to evaluate
an LSRH's compliance following a complaint of abuse, neglect, or exploitation;
or a complaint related to the health and safety of patients. HHSC
may coordinate complaint investigations with the federal Centers for
Medicare & Medicaid Services and its agents responsible for surveying
LSRHs to determine compliance with the conditions of participation
under Title XVIII of the Social Security Act, (42 USC, §§1395
et seq), to avoid duplicate investigations.
(e) HHSC may conduct an unannounced, on-site investigation
of an LSRH at any reasonable time, including when treatment services
are provided, to inspect or investigate:
(1) an LSRH's compliance with any applicable statute
or rule;
(2) an LSRH's plan of correction;
(3) an LSRH's compliance with an order of the executive
commissioner or the executive commissioner's designee;
(4) an LSRH's compliance with a court order granting
injunctive relief; or
(5) for other purposes relating to regulation of the
LSRH.
(f) An applicant or licensee, by applying for or holding
a license, consents to entry and investigation of any of its LSRHs
by HHSC.
(g) An LSRH shall cooperate with any HHSC investigation
and shall permit HHSC to examine the LSRH's grounds, buildings, books,
records, video surveillance, and other documents and information maintained
by, or on behalf of, the LSRH.
(h) An LSRH shall permit HHSC access to interview members
of the governing body, personnel, and patients, including the opportunity
to request a written statement.
(i) An LSRH shall permit HHSC to inspect and copy any
requested information. If it is necessary for HHSC to remove documents
or other records from the LSRH, 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.
(j) HHSC shall maintain the confidentiality of LSRH
records as applicable under state or federal law. All information
and materials obtained or compiled by HHSC in connection with an investigation
are confidential and not subject to disclosure under Texas Government
Code Chapter 552 (relating to Public Information), and not subject
to disclosure, discovery, subpoena, or other means of legal compulsion
for their release to anyone other than HHSC or its employees or agents
involved in the enforcement action except that this information may
be disclosed to:
(1) persons involved with HHSC in the enforcement action
against the LSRH;
(2) the LSRH that is the subject of the enforcement
action, or the LSRH's authorized representative;
(3) appropriate state or federal agencies that are
authorized to inspect, survey, or investigate LSRH services;
(4) law enforcement agencies; and
(5) persons engaged in bona fide research, if all individual-identifying
and LSRH-identifying information has been deleted.
(k) The following information is subject to disclosure
in accordance with Texas Government Code Chapter 552:
(1) a notice of alleged violation against the LSRH,
which notice shall include the provisions of law that the LSRH is
alleged to have violated, and a general statement of the nature of
the alleged violation;
(2) the pleadings in the administrative proceeding;
(3) a final decision or order by HHSC; and
(4) any other information required by law to be disclosed
under public information request laws.
(l) On entry, HHSC holds an entrance conference with
the LSRH's designated representative to explain the nature, scope,
and estimated duration of the investigation.
(m) HHSC holds an exit conference with the LSRH representative
to inform the LSRH representative of any preliminary findings of the
investigation. The LSRH may provide any final documentation regarding
compliance during the exit conference.
(n) Once HHSC completes an investigation, 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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