SECTION 554.910. Quality Assurance Early Warning System

The Health and Human Services Commission (HHSC) uses an early warning system to detect conditions that could be detrimental to the health, safety, and welfare of residents.

(1) Quality-of-care monitors conduct visits that may be announced or unannounced and may occur on any day and at any time, including nights, weekends, and holidays.

(2) Quality-of-care monitors may visit a facility:

(A) with a history of resident care deficiencies;

(B) that is identified as a medium risk through the early warning system; or

(C) that requests a visit.

(3) Quality-of-care monitors assess:

(A) the overall quality of life in the facility; and

(B) specific conditions in the facility directly related to resident care, including conditions identified through the facility's quality measure reports based on MDS assessments.

(4) A quality-of-care monitor assessment visit includes:

(A) observation of the care and services provided to a resident; and

(B) formal and informal interviews with residents, family members, facility staff, resident guests, volunteers, other regular staff, and resident representatives and advocates.

(5) HHSC does not disclose the identity of a resident or family member of a resident interviewed by a quality-of-care monitor unless required by law to do so.

(6) A quality-of-care monitor provides the findings of a monitoring visit, both positive and negative, orally and in writing to the facility administrator or, in the absence of the facility administrator, to the administrator on duty or the director of nursing.

(7) A quality-of-care monitor may recommend to the facility administrator procedural and policy changes and staff training to improve the care or quality of life of residents.

(8) A quality-of-care monitor conducts a follow-up visit within 45 days after the date of an initial visit.

(9) A quality-of-care monitor who observes conditions that may constitute an immediate threat to the health or safety of a resident immediately reports the conditions to the facility administrator, the monitor's regional office supervisor for appropriate action and, as appropriate, to law enforcement, adult protective services, other divisions of HHSC, and other agencies.

Source Note: The provisions of this §554.910 adopted to be effective May 1, 2002, 27 TexReg 3207; amended to be effective June 1, 2006, 31 TexReg 4458; amended to be effective March 27, 2017, 42 TexReg 1575; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871