Current through Reg. 50, No. 13; March 28, 2025
(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.
