SECTION 133.102. Complaint Against a Department of State Health Services Surveyor

(a) A hospital may register a complaint against a Department of State Health Services surveyor who conducts an inspection or investigation in accordance with §133.101 of this title (relating to Inspection and Investigation Procedures).

(b) A complaint against a surveyor shall be registered with the Patient Quality Care Unit, Department of State Health Services, 1100 West 49th Street, Austin, Texas 78756-3199, telephone [phone] or [phone].

(1) A complaint against a surveyor which is received by telephone will be referred within two working days to the appropriate supervisor. The caller will be requested to submit the complaint in writing.

(2) When a complaint is received in writing, it will be forwarded to the appropriate supervisor within two working days. Within 10 calendar days of receipt of the complaint, the department will inform the complainant in writing that the complaint has been forwarded to the appropriate supervisor.

(3) Within 10 calendar days of the supervisor's receipt of the complaint, the supervisor will notify the complainant in writing that an investigation will be done.

(4) 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 hospital's inspection or investigation.

(5) 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.

(6) The supervisor will document the investigation. A report of the investigation will be placed in the hospital's 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.

(7) 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.

(8) Changes and deletions will be made to the inspection report, if necessary.

(9) The supervisor will notify the complainant in writing of the status of the investigation within 30 calendar days of the date the supervisor received the complaint.

(10) The supervisor will forward all final documentation to the director of the Patient Quality Care Unit and notify the complainant of the results.

Source Note: The provisions of this §133.102 adopted to be effective June 21, 2007, 32 TexReg 3587