SECTION 551.191. Procedural Requirements

(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.

Source Note: The provisions of this §551.191 adopted to be effective August 31, 1993, 18 TexReg 2557; transferred effective September 1, 1993, as published in the Texas Register September 3, 1993, 18 TexReg 5885; amended to be effective September 1, 1994, 19 TexReg 5731; amended to be effective May 1, 1995, 20 TexReg 1659; amended to be effective May 1, 1998, 23 TexReg 4060; amended to be effective July 1, 2002, 27 TexReg 5525; amended to be effective October 29, 2018, 43 TexReg 7196; transferred effective May 1, 2019, as published in the Texas Register April12,2019, 44 TexReg 1883; amended to be effective February 24, 2022, 47 TexReg 787