| (a) HHSC inspection and survey personnel perform inspections
and surveys, follow-up visits, complaint investigations, investigations
of abuse or neglect, and other contact visits from time to time as
they deem appropriate or as required for carrying out the responsibilities
of licensing.
(b) An inspection may be conducted by an individual
qualified surveyor or by a team, of which at least one member is a
qualified surveyor.
(c) To determine standard compliance which cannot be
verified during regular working hours, night or weekend inspections
may be conducted to cover specific segments of operation and will
be completed with the least possible interference to staff and residents.
(d) Generally, all inspections, surveys, complaint
investigations and other visits, whether routine or non-routine, made
for the purpose of determining the appropriateness of resident care
and day-to-day operations of a facility will be unannounced; any exceptions
must be justified. Releasing advance information of an unannounced
inspection is a third degree felony, as provided in §242.045
of the Health and Safety Code.
(e) Certain visits may be announced, including, but
not limited to, consultation visits to determine how a physical plant
may be expanded or upgraded and visits to determine the progress of
physical plant construction or repairs, equipment installation or
repairs, or systems installation or repairs or conditions when certain
emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning
of electrical or mechanical systems.
(f) Persons authorized to receive advance information
on unannounced inspections include:
(1) citizen advocates invited to attend inspections,
as described in subsection (g) of this section;
(2) the State Ombudsman, a certified ombudsman, and
an ombudsman intern who are authorized to attend and participate in
inspections;
(3) representatives of the United States Department
of Health and Human Services whose programs relate to the Medicare/Medicaid
Long Term Care Program; and
(4) representatives of HHSC whose programs relate to
the Medicare/Medicaid long term care program.
(g) HHSC conducts at least one unannounced inspection
annually of each institution licensed under Health and Safety Code,
Chapter 242, except as provided for in this subsection. For purposes
of this subsection, "annually" means a statewide average of once every
12 months.
(1) In order to ensure continuous compliance, a sufficient
number of inspections will be conducted between the hours of 5:00
p.m. and 8:00 a.m. in randomly selected institutions. This cursory
after-hours inspection is conducted to verify staffing, assurance
of emergency egress, resident care, medication security, food service
or nourishments, sanitation, and other items as deemed appropriate.
To the greatest extent feasible, any disruption of the residents is
minimal.
(2) For at least one unannounced inspection annually,
HHSC invites to the inspections at least one person as a citizen advocate
from the Ombudsman Program or any other statewide organization for
older adults. HHSC provides to these organizations basic licensing
information and requirements for the organizations' dissemination
to their members whom they engage to attend the inspections. Advocates
participating in the inspections must follow all protocols of HHSC.
Advocates provide their own transportation. The schedule of inspections
in this category are arranged confidentially in advance with the organizations.
Participation by the advocates is not a condition precedent to conducting
the inspection.
(h) The facility must make all of its books, records,
and other documents maintained by or on behalf of a facility accessible
to HHSC upon request.
(1) During an inspection, survey, or investigation,
HHSC is authorized to photocopy documents, photograph residents, and
use any other available recordation devices to preserve all relevant
evidence of conditions that HHSC reasonably believes threaten the
health and safety of a resident.
(2) Examples of records and documents which may be
requested and photocopied or otherwise reproduced are resident medical
records, including nursing notes, pharmacy records medication records,
and physician's orders.
(3) When the facility is requested to furnish the copies,
the facility may charge HHSC at the rate not to exceed the rate charged
by HHSC for copies. The procedure of copying is the responsibility
of the administrator or his designee. If copying requires the records
be removed from the facility, a representative of the facility is
expected to accompany the records and assure their order and preservation.
(4) HHSC protects the copies for privacy and confidentiality
in accordance with recognized standards of medical records practice,
applicable state laws, and HHSC policy.
(i) HHSC provides for a special team to conduct validation
surveys or verify findings of previous licensure surveys.
(1) At HHSC's discretion, based on record review, random
sample, or any other determination, HHSC may assign a team to conduct
a validation survey. HHSC may use the information to verify previous
determinations or identify training needs to assure consistency in
deficiencies cited and in punitive actions recommended throughout
the state.
(2) Facilities are required to correct any additional
deficiencies cited by the validation team but are not subject to any
new or additional punitive action.
|
| Source Note: The provisions of this §554.2002 adopted to be effective May 1, 1995, 20 TexReg 2393; amended to be effective March 1, 1998, 23 TexReg 1314; amended to be effective April 5, 2018, 43 TexReg 2017; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871; amended to be effective December 6, 2022, 47 TexReg 7712 |
