Survey is over! Now what?

HHSC has come and gone and your survey is now complete, so here you are either celebrating or looking to pick up the pieces and move forward. Now it’s time to take the surveyor’s feedback and use it to make direct changes that reflect in the care of your residents. Check out the following regulation on what to expect when the survey is over:

RULE 553.82   Determinations and Actions

(a) DADS determines if a facility meets DADS licensing rules, including physical plant and facility operation requirements, by conducting inspections, surveys, investigations, and on-site visits.

(b) DADS lists violations of licensing rules on a report of contact. The report of contact includes a specific reference to a licensing rule that has been violated.

(c) At the conclusion of an inspection, survey, investigation, or on-site visit, a DADS surveyor conducts an exit conference to advise the facility of the findings resulting from the inspection, survey, investigation, or on-site visit.

(d) At the exit conference, the surveyor provides a copy of the report of contact described in subsection (b) of this section to the facility.

(e) If, after the initial exit conference, a DADS surveyor cites an additional licensing rule violation, the surveyor conducts another exit conference regarding the newly identified violations, and updates the report of contact with a specific reference to the licensing rule that has been violated.

(f) DADS provides to the facility a written statement of violations from an inspection, survey, investigation, or on-site visit on DADS Form 3724 within 10 days after the final exit conference. The statement of violations includes a clear and concise summary in nontechnical language of each licensing rule violation. The statement of violations does not include names of residents or staff, statements that identify a resident, or other prohibited information.

(g) A facility must submit an acceptable plan of correction to the DADS regional director within 10 days after receiving the statement of violations described in subsection (f) of this section. An acceptable plan of correction must address:

(1) how corrective action will be accomplished for a resident affected by a violation of a licensing rule;

(2) how the facility will identify other residents who may be affected by the violation of the licensing rule;

(3) how the corrective action the facility implements will ensure the violation does not reoccur;

(4) how the facility will monitor its corrective action to ensure the violation is being corrected and will not reoccur; and

(5) dates when corrective action will be completed.

Pro Tip:

  • Ensure you provide DADS with an actionable plan of correction in a timely manner. If they see you have taken your due diligence with enacting this plan things should move forward smoothly!