Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 139 - ABORTION FACILITY REPORTING AND LICENSING
Subchapter C - ENFORCEMENT
Section 139.31 - On-Site Inspections and Complaint Investigations of a Licensed Abortion Facility
Universal Citation: 25 TX Admin Code ยง 139.31
Current through Reg. 49, No. 38; September 20, 2024
(a) General. An on-site inspection shall determine if the requirements of the Act and this chapter are being met.
(1) An authorized
representative of the commission (surveyor) may enter the premises of a
licensed abortion facility at reasonable times during business hours and at
other times as it considers necessary to ensure compliance with:
(A) the Act and this chapter;
(B) an order of the executive
commissioner;
(C) a court order
granting injunctive relief; or
(D)
other enforcement actions.
(2) The surveyor is entitled to access all
books, records, or other documents maintained by or on behalf of the facility
to the extent necessary to ensure compliance with the Act, this chapter, an
order of the executive commissioner, a court order granting injunctive relief,
or other enforcement action. The commission shall maintain the confidentiality
of facility records as applicable under federal or state law. Ensuring
compliance includes permitting photocopying by a department surveyor or
providing photocopies to a commission surveyor of any records or other
information by or on behalf of the commission as necessary to determine or
verify compliance with the Act or this chapter.
(3) By applying for or holding a license, the
facility consents to entry and inspection of the facility by the commission or
representative of the commission in accordance with the Act and this
chapter.
(b) Inspection procedures.
(1) Except for purposes of an
initial license application, all on-site inspections shall be unannounced and
conducted at least annually. An on-site inspection for an initial license
application, in accordance with §
139.23(c)
of this title (relating to Application Procedures and Issuance of Licenses),
shall be scheduled with the applicant.
(2) The commission's surveyor shall hold a
conference with the person who is in charge of a licensed abortion facility or
a facility subject to an application prior to commencing the inspection for the
purpose of explaining the nature and scope of the inspection. The surveyor
shall hold an exit conference with the person who is in charge of the facility
when the inspection is completed, and the surveyor shall identify any records
that were duplicated. Any original facility records that are removed from a
facility shall be removed only with the consent of the facility.
(3) The commission's authorized
representative shall hold an exit conference and fully inform the person who is
in charge of the facility of the preliminary finding(s) of the inspection, and
shall give the person a reasonable opportunity to submit additional facts or
other information to the surveyor in response to those findings. The response
shall be made a part of the inspection for all purposes, and shall be received
by the commission within 14 calendar days of receipt of the preliminary
findings of the inspection by the facility.
(4) After the inspection is completed, the
commission shall provide the administrator of the facility specific and timely
written notice of the findings of the inspection in accordance with paragraph
(7) of this subsection.
(5) If the
commission determines that the facility is in compliance with minimum standards
at the time of the on-site inspection, the commission shall issue a license to
the facility, if applicable.
(6) If
the surveyor finds there are deficiencies, the commission shall provide the
facility with a statement of the deficiencies; the surveyor's recommendation
for further action; or if there are no deficiencies found, a statement
indicating this fact.
(7) If the
commission representative finds there are deficiencies, the facility and the
commission shall comply with the following procedure.
(A) The commission shall provide the facility
with a statement of deficiencies on site at the time of the exit conference or
within 14 calendar days of the exit conference.
(B) The facility administrator or person in
charge shall sign the written statement of deficiencies and return it to the
commission with its plan of correction(s) for each deficiency within 14
calendar days of its receipt of the statement of deficiencies. The signature
does not indicate the person's agreement with deficiencies stated on the
form.
(C) The facility shall have
the option to challenge any deficiency cited after receipt of the statement of
deficiencies. A challenge to a deficiency(ies) shall be in accordance with this
subparagraph.
(i) An initial challenge to a
deficiency(ies) shall be submitted in writing no later than 14 calendar days
from the facility's receipt of the statement of deficiencies to the Manager,
Health Care Quality, Health Facility Compliance Texas Health and Human Services
Commission, Post Office Box 149347, Austin, Texas 78714-9347. The initial
written challenge shall include any and all documents supporting the facility's
position.
(ii) If the initial
challenge is favorable to the commission, the facility may request a review of
the initial challenge by submitting a written request to the Director, Health
Care Quality, Texas Health and Human Services Commission, Post Office Box
149347, Austin, Texas 78714-9347. The facility shall submit its written request
for review of the initial challenge no later than 14 calendar days of its
receipt of the commission's response to the initial challenge. The commission
shall not accept or review any documents that were not submitted with the
initial challenge. A determination by the Director of Health Care Quality,
relating to a challenge to a deficiency(ies) shall be considered the final
determination by the commission .
(iii) The commission shall respond to any
written challenge submitted under clauses (i) or (ii) of this subparagraph no
later than 14 calendar days from its receipt.
(D) The commission shall determine if the
written plan of correction is acceptable. If the plan of correction(s) is not
acceptable to the commission, the commission shall notify the facility and
request that the plan of correction be modified by telephone or resubmitted no
later than 14 calendar days from receipt of such request by the
facility.
(E) If the facility does
not come into compliance by the required date of correction, the commission may
propose to deny, suspend, place on probation, or revoke the license in
accordance with §
139.32
of this title (relating to License Denial, Suspension, Probation, or
Revocation).
(F) Acceptance of a
plan of correction by the commission does not preclude the commission from
taking enforcement action as appropriate under §
139.32
of this title.
(8) The
commission shall refer issues and complaints relating to the conduct or
action(s) by licensed health care professionals to their appropriate licensing
boards.
(c) Complaints.
(1) In accordance with §
139.50 of
this title (relating to Disclosure Requirements), all licensed abortion
facilities are required to provide the woman on whom the abortion is to be
performed and her guardian, if present, if the patient is a minor at time of
the initial visit or if guardianship is required, with a written statement that
complaints relating to the abortion facility may be registered with the
Manager, Health Care Quality, Health Facility Compliance, Texas Health and
Human Services Commission, Post Office Box 149347, Austin, Texas 78714-9347,
(888) 973-0022.
(2) The commission
shall evaluate all complaints against licensed abortion facilities. All
complaints submitted to the commission shall be in writing and signed by the
complainant. Only those allegations determined to be relevant to the Act or
this chapter shall be authorized for investigation. All information pertaining
to a complaint is strictly confidential.
(3) The commission or its authorized
representative may enter the premises of an abortion facility during normal
business hours as necessary to assure compliance with the Act and this chapter.
The investigation may be conducted on site, by phone or by mail.
(4) Conduct of the on-site investigation of a
licensed abortion facility shall include, but not be limited to:
(A) a conference prior to commencing the
on-site investigation for the purpose of explaining the nature and scope of the
investigation between the commission's authorized representative and the
administrator of the abortion facility, or his or her designee;
(B) an inspection of the facility;
(C) an inspection of medical records,
personnel records, administrative files, reports, other records, and/or working
papers;
(D) an interview with any
physician or other health care practitioner, including abortion facility
personnel who care for the recipient of abortion services;
(E) a conference at the conclusion of the
inspection between the commission's representative and the administrator, or
his or her designee of the facility; and
(F) identification by the commission's
representative of any facility documents that have been reproduced.
(5) If the commission finds that
there are deficiencies following the on-site inspection, the provisions of
subsection (b)(6) and (7) of this section shall apply.
(6) The commission shall review the report of
the investigation and determine the validity of the complaint.
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