One of the most pivotal times facility staff faces is inspection and survey time. These can be some of the most stressful times for the community due to the increased pressure of having your license and reputation on the line and at the judgment of a surveyor. Fear not my friends, as you have planned for this moment and hopefully have implemented policies and procedures designed to meet the requirements of the Texas HHSC regulations. Check out the regulation below as to what to expect when a surveyor visits your community:
RULE 553.81 Inspections and Surveys
(a) HHSC inspection and survey personnel will perform inspections and surveys, follow-up visits, complaint investigations, investigations of abuse or neglect, and other contact visits from time to time as they deem appropriate or as required for carrying out the responsibilities of licensing.
(b) In addition to the inspections required under 92.14 of this chapter (relating to Initial License Application Procedures and Requirements), HHSC inspects a facility at least once every two years after the initial inspection.
(c) An inspection may be conducted by an individual surveyor or by a team, depending on the purpose of the inspection or survey, size of the facility, and service provided by the facility, and other factors.
(d) To determine standard compliance which cannot be verified during regular working hours, night or weekend inspections may be conducted to cover specific segments of operation and will be completed with the least possible interference to staff and residents.
(e) Generally, all inspections, surveys, complaint investigations, and other visits, whether routine or nonroutine, made for the purpose of determining the appropriateness of resident care and day-to-day operations of a facility will be unannounced; any exceptions must be justified.
(f) Certain visits may be announced, including, but not limited to, conditions when certain emergencies arise, such as fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.
(g) The facility must make all books, records, and other documents maintained by or on behalf of a facility accessible to HHSC upon request.
(1) HHSC is authorized to photocopy documents, photograph residents, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection, survey, or investigation that HHSC reasonably believes threaten the health and safety of a resident.
(2) Records and documents which may be requested and photocopied or otherwise reproduced include, but are not limited to, admission sheets, medication profiles, observation notes, medication refusal notes, and menu records.
(3) When the facility is requested to furnish the copies, the facility may charge HHSC at the rate not to exceed the rate charged by HHSC for copies. Collection must be by billing HHSC. The procedure of copying is the responsibility of the administrator or his designee. If copying requires the removal of the records from the facility, a representative of the facility will be expected to accompany the records and assure their order and preservation.
(4) HHSC will protect the copies for privacy and confidentiality in accordance with recognized standards of medical records practice, applicable state laws, and HHSC policy.
Pro Tip:
- Work with the surveyor and their team’s needs
- Be professional and try to develop a rapport with the surveyor
- Be honest
- Use their feedback to make needed changes to your facility
Remember, they are not here to hurt your facility. They are there to make sure we as operators are doing all we can do to ensure residents are being cared for in the best way possible.