01. Surveys of Facilities. As described in Section 39-3355, Idaho Code, the Licensing Agency will
conduct inspections and investigations at specified intervals to determine compliance with this chapter of rules and
Title 39, Chapter 33, Idaho Code. The intervals for surveys are as follows:

a. Initial surveys will be conducted within ninety (90) days of licensure, followed by a licensure
survey within fifteen (15) months.
b. Facilities without core issue deficiencies during two (2) consecutive surveys, either initial or
licensure surveys, will be inspected at least every thirty-six (36) months. For facilities with core issue deficiencies
during any survey, surveys will be conducted at the discretion of the Licensing Agency, at least every twelve (12)
months.
c. Complaint investigation surveys will occur based on the potential severity of the complaint.

02. Unannounced Inspections. Licensure, follow-up, and complaint investigation surveys are made
unannounced and without prior notice.

03. Inspection or Survey Services. The Department may accept the services of any qualified person or
organization, either public or private, to examine, survey, or inspect any entity requesting or holding a facility license,
including as described in Section 39-3355(7), Idaho Code.
04. Access and Authority to Entire Facility. A surveyor must have full access and authority to
examine:
a. Quality of care;
b. Service delivery;
c. Resident records;
d. Facility records, including any records or documents pertaining to any financial transactions
between residents and the facility or any of its employees;
e. Resident accounts;
f. The physical premises, including buildings, grounds, equipment, food service, water supply, and
housekeeping; and
g. Any other areas necessary to determine compliance with applicable statute, rules, and standards.

05. Interview Authority. A surveyor has the authority to interview any individual associated with the
facility or the provision of care, including the licensee, administrator, staff, residents, residents’ families, outside
service providers, and authorized providers or physicians. Interviews are confidential and conducted privately unless
otherwise specified by the interviewee.

06. Access to Staff Living Quarters. A surveyor has full authority to inspect the facility, including
personal living quarters of the licensee, administrator, or staff living in the facility, to check for inappropriate storage

of combustibles, faulty wiring, or other conditions that may have a direct impact on compliance with these rules.
07. Written Report of Deficiencies. The Licensing Agency will provide the facility a written report to
support any deficiencies identified.
a. The Licensing Agency will provide the facility a written report specifying the non-core issue
deficiencies at the time of the exit conference.
b. When core issues are identified during a survey, the Licensing Agency will provide a written report
within ten (10) business days of the exit conference or the last day of receipt of additional material.
c. If any deficiencies pose an immediate danger to the residents, the Department requires immediate
correction of the deficient practice.

08. Plan of Correction for Core Issues. The facility must develop and submit an acceptable plan of
correction to the Licensing Agency within ten (10) calendar days of receipt of the written report of identified core
issues. If an acceptable plan of correction is not submitted within the required time frame, the Department may
initiate or extend enforcement actions as described in Sections 900 through 940 of these rules. An acceptable plan of
correction must include:
a. A plan to ensure correction of each deficient practice and ongoing compliance;
b. A description of how, and at what frequency, corrective actions will be monitored to ensure that
each deficient practice is corrected and will not recur, such as what program will be put into place to monitor the
continued effectiveness of the systemic change; and
c. The completion date for correcting each deficiency. No correction date may be more than forty five (45)
days from the exit date printed on the written report except in unusual circumstances and only with the
written approval of the Licensing Agency.

09. Correction of Non-Core Issues. The facility must correct non-core issues within thirty (30)
calendar days of the exit conference. If there are non-core issues that the facility is unable to resolve due to
extenuating circumstances, a written request for the delay must be submitted for Licensing Agency approval within
thirty (30) days of the exit conference. The request must contain the following information:
a. The reason for the delay;
b. A plan for resolution;
c. The date of the expected resolution, which may not exceed six (6) months; and
d. A plan for ensuring the safety of the residents until resolution.
10. Follow-Up Surveys. The Licensing Agency will conduct follow-up surveys to ascertain
corrections to issues are made according to the time frames established in the plan of correction for core issues and
within thirty (30) days for non-core issues. If the Department identifies repeat deficient facility practice(s) during any
follow-up survey, the Department may initiate or extend enforcement actions as described in Sections 900 through
940 of these rules.

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