Current through Reg. 50, No. 13; March 28, 2025
(a) Texas
Health and Human Services Commission (HHSC) inspection and survey staff must
perform inspections, surveys, follow-up visits, complaint investigations,
investigations of abuse or neglect, and other contact visits from time to time
as HHSC deems appropriate or as required for carrying out the responsibilities
of licensing.
(b) A qualified
surveyor or a team, of which one member is a specialized staff person who has
expertise in developmental disabilities, conducts an inspection.
(c) To determine standard compliance that
cannot be determined during regular working hours, HHSC may conduct night or
weekend inspections to cover specific segments of operation. HHSC completes the
inspections with the least possible interference to staff and
residents.
(d) Generally, HHSC does
not announce an inspection, survey, complaint investigation, or other visit,
whether routine or non-routine, made for determining the appropriateness of
resident care and day-to-day operations of a facility.
(e) HHSC may announce certain visits,
including:
(1) an initial life safety code
inspection;
(2) a life safety code
capacity increase inspection;
(3) a
final construction inspection;
(4)
a visit to determine the progress of physical plant construction or repairs,
equipment installation or repairs, or systems installation or repairs;
or
(5) a visit resulting from an
emergency, including a fire, a windstorm, or malfunctioning or nonfunctioning
electrical or mechanical systems.
(f) Persons authorized to receive advance
notice of unannounced inspections include:
(1)
citizen advocates invited to attend inspections, as described in subsection (g)
of this section;
(2)
representatives of the United States Department of Health and Human Services
whose programs relate to the Medicare/Medicaid long-term care program
;and
(3) representatives of HHSC
whose programs relate to the Medicare/Medicaid long-term care
program.
(g) HHSC
conducts at least three unannounced inspections of a facility during a
three-year licensing period.
(1) HHSC conducts
a sufficient number of inspections between the hours of 5:00 p.m. and 8:00 a.m.
In randomly selected facilities, HHSC conducts a cursory after-hours inspection
to determine staffing, emergency egress, resident care, medication security,
food service or nourishments, sanitation, and other items determined necessary
by HHSC. HHSC completes the inspections with minimal disruption to staff and
residents.
(2) For at least two
unannounced inspections each licensing period, HHSC may invite to the
inspections at least one person as a citizen advocate who has an interest in or
who is employed by or affiliated with an organization or agency that represents
or advocates for persons with an intellectual disability or a related
condition. 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 HHSC protocols. Advocates must provide their own
transportation. The schedule of inspections in this category will be arranged
confidentially in advance with the organizations. Participation by the
advocates is not a condition precedent to conducting the inspection.
(h) A facility must make all
books, records, and other documents that are maintained by or on behalf of the
facility accessible to HHSC on request.
(1)
HHSC may photocopy documents, photograph residents, and use any other available
recording devices to preserve relevant evidence of conditions found during an
inspection, survey, or investigation.
(2) Examples of records that HHSC may request
and photocopy or otherwise reproduce are resident medical records, including
nursing notes, pharmacy records, medication records, and physician's
orders.
(3) When HHSC requests a
facility furnish copies of documents, the facility may charge HHSC at a rate
not to exceed the rate charged by HHSC for copies. The administrator or
designee must ensure the documents are copied. If the documents must be removed
from the facility to be copied, a representative of the facility must accompany
the documents and ensure 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.
(5) A facility must not falsify information
contained in resident records.
(i) HHSC may provide a special team to
conduct validation surveys or to 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 ensure consistency in deficiencies
cited and in punitive actions recommended throughout the state.
(2) A facility must correct any additional
deficiencies cited by a validation team but is not subject to any new or
additional punitive action as a result of those deficiencies.
(j) During an investigation,
survey, or inspection, HHSC may conduct an interview with a resident of a
facility or staff employed by the facility in private. A facility must not
retaliate against the resident or staff.
(k) Facility staff must be available at the
facility within 45 minutes of telephone contact by survey staff.
