| (vii) If the facility does not come into compliance by the required date of correction reflected on the corrective action plan(s), the department may: (I) appoint a monitor as described in §117.81 of this title (relating to Corrective Action Plan); (II) appoint a temporary manager as described in §117.83 of this title (relating to Involuntary Appointment of a Temporary Manager); (III) propose to deny, suspend, or revoke the license in accordance with §117.84 of this title (relating to Disciplinary Action); (IV) assess an administrative penalty(ies) in accordance with §117.85 of this title (relating to Administrative Penalties); or (V) take all of the actions described in subclauses (I) - (IV) of this clause. (viii) The department may verify the correction of deficiencies by mail or on-site inspection. (ix) Acceptance of a corrective action plan does not preclude the department from taking enforcement action as appropriate under §§117.83, 117.84, or 117.85 of this title. (x) The department shall refer issues and complaints relating to the conduct of or action(s) by licensed health care professionals to the appropriate licensing board(s). (d) Complaint against a department surveyor. (1) An ESRD facility may register a complaint against a Department of State Health Services surveyor who conducts an inspection or investigation. (2) A complaint against a surveyor shall be registered with the Patient Quality Care Unit, Department of State Health Services, Mail Code 1979, P.O. Box 149347, Austin, Texas 78714-9347, telephone (512) 834-6650 or (888) 973-0022. (A) A complaint against a surveyor which is received by telephone will be referred not later than the second working day to the appropriate supervisor. The caller will be requested to submit the complaint in writing. (B) When a complaint is received in writing, it will be forwarded to the appropriate supervisor not later than the second working day. Not later than the 10th calendar day after the department receives the complaint, the department will inform the complainant in writing that the complaint has been forwarded to the appropriate supervisor. (C) Not later than the 10th calendar day after the supervisor receives the complaint, the supervisor will notify the complainant in writing that an investigation will be done. (D) The supervisor will review the documentation in the survey packet and interview the surveyor identified in the complaint to obtain facts and assess the objectivity of the surveyor in the surveyor's application of this chapter during the ESRD facility's inspection or investigation. (E) The supervisor will review the applicable rules, personnel policies, and review the training and qualifications of the surveyor as it relates to the inspection or investigation. (F) The supervisor will document the investigation. A report of the investigation will be placed in the ESRD facility file if the complaint and investigation affected the inspection process. A counseling form will be used and placed in the surveyor's personnel file if the complaint relates to personnel performance. (G) The supervisor shall offer to meet with the complainant to resolve the issue. The surveyor identified in the complaint will participate in the discussion. The resolution meeting may be conducted at the division's office or during an on-site follow-up visit to the hospital. (H) Changes and deletions will be made to the inspection report, if necessary. (I) The supervisor will notify the complainant in writing of the status of the investigation not later than the 30th calendar day after the date the supervisor received the complaint. (J) The supervisor will forward all final documentation to the director of the Patient Quality Care Unit and notify the complainant of the results. |
