Current through Reg. 49, No. 38; September 20, 2024
(a) After a
survey is completed, the surveyor holds an exit conference with the
administrator or alternate administrator to inform the agency of the
preliminary findings.
(b) An agency
may make an audio recording of the exit conference only if the agency:
(1) records two tapes
simultaneously;
(2) allows the
surveyor to review the tapes; and
(3) gives the surveyor the tape of the
surveyor's choice before leaving the agency.
(c) An agency may make a video recording of
the exit conference only if the surveyor agrees to allow it and if the agency:
(1) records two tapes
simultaneously;
(2) allows the
surveyor to review the tapes; and
(3) gives the surveyor the tape of the
surveyor's choice before leaving the agency.
(d) An agency may submit additional written
documentation and facts after the exit conference only if the agency describes
the additional documentation and facts to the surveyor during the exit
conference.
(1) The agency must submit the
additional written documentation and facts to the designated survey office
within two working days after the end of the exit conference.
(2) If an agency properly submits additional
written documentation, the surveyor may add the documentation to the record of
the survey.
(e) If HHSC
identifies additional violations or deficiencies after the exit conference,
HHSC holds an additional face-to-face exit conference with the agency regarding
the additional violations or deficiencies.
(f) HHSC provides official written
notification of the survey findings to the agency within 10 working days after
the exit conference.
(g) The
official written notification of the survey findings includes a statement of
violations, condition-level deficiencies, or both, cited by HHSC against the
agency as a result of the survey, and instructions for submitting an acceptable
plan of correction, and for requesting IDR.
(1) If the official written notification of
the survey findings declares that an agency is in violation of the Statute or
this chapter, an agency must follow HHSC instructions included with the
statement of violations for submitting an acceptable plan of
correction.
(2) An acceptable plan
of correction includes the corrective measures and time frame with which the
agency must comply to ensure correction of a violation. If an agency fails to
correct each violation by the date on the plan of correction, HHSC may take
enforcement action against the agency. An agency must correct a violation in
accordance with the following time frames:
(A) A Severity Level B violation that results
in serious harm to or death of a client or constitutes a serious threat to the
health or safety of a client, must be addressed upon receipt of the official
written notice of the violations and corrected within two days.
(B) A Severity Level B violation that
substantially limits the agency's capacity to provide care must be corrected
within seven days after receipt of the official written notice of the
violations.
(C) A Severity Level A
violation that has or had minor or no health or safety significance must be
corrected within 20 days after receipt of the official written notice of the
violations.
(D) A violation that is
not designated as Severity Level A or Severity Level B must be corrected within
60 days after the date the violation was cited.
(3) An agency must submit an acceptable plan
of correction for each violation or deficiency no later than 10 days after its
receipt of the official written notification of the survey findings.
(4) If HHSC finds the plan of correction
unacceptable, HHSC gives the agency written notice and provides the agency one
additional opportunity to submit an acceptable plan of correction. An agency
must submit a revised plan of correction no later than 30 days after the
agency's receipt of HHSC written notice of an unacceptable plan of
correction.
(h) An
acceptable plan of correction does not preclude HHSC from taking enforcement
action against an agency.
(i) An
agency must submit a plan of correction in response to an official written
notification of survey findings that declares a violation or deficiency even if
the agency disagrees with the survey findings.
(j) If an agency disagrees with the survey
findings citing a violation or condition-level deficiency, the agency may
request IDR to refute the violation or deficiency.
(1) HHSC does not grant an agency's request
for IDR if:
(A) HHSC cited the violation or
deficiency at the agency's immediately preceding survey; and
(B) HHSC cited the violation or deficiency
again, with no new findings.
(2) To request IDR, an agency must:
(A) mail or fax a complete and accurate IDR
request form to the address or fax number listed on the form, which must be
postmarked or faxed within 10 days after the date of receipt of the official
written notification of the survey findings;
(B) mail or fax a rebuttal letter and
supporting documentation to the address or fax number listed on the IDR request
form and ensure receipt by the HHSC Survey and Certification Enforcement Unit
within seven days after the postmark or fax date of the IDR request form;
and
(C) mail or fax a copy of the
IDR request form, rebuttal letter, and supporting documentation to the
designated survey office within the same time frames each is submitted to the
HHSC Survey and Certification Enforcement Unit.
(3) An agency may not submit information
after the deadlines established in paragraph (2)(A) and (B) of this subsection
unless HHSC requests additional information. The agency's response to HHSC
request for information must be received within three working days after the
request is made.
(4) An agency
waives its right to IDR if the agency fails to submit the required information
to the HHSC Survey and Certification Enforcement Unit within the required time
frames.
(5) An agency must present
sufficient information to the HHSC Survey and Certification Enforcement Unit to
support the agency's desired IDR outcome.
(6) The rebuttal letter and supporting
documentation must include:
(A)
identification of the disputed deficiencies or violations;
(B) the reason the deficiencies or violations
are disputed;
(C) the desired
outcome for each disputed deficiency or violation; and
(D) copies of client records, policies and
procedures, and other documentation and information that directly demonstrate
that the condition-level deficiency or violation should not have been
cited.
(7) The written
decision issued by HHSC after the completion of its review is the final
decision from IDR.
