What to expect during an inspection

Let’s face it- inspection time is extremely stressful! No matter how much you have prepared or how long you have been in the “industry” when an inspector shows up to your community it can be a nerve-wracking experience. In Washington DC, The Community Residence Facilities Branch, Child and Residential Care Facilities Division, Health Regulation Administration can show up anytime they see fit to conduct an inspection of every nook and cranny of the facility. Be prepared, be cordial and be open with inspectors and you will certainly have a much better experience. Check out the following regulation for what to expect during the inspection process:

10107 INSPECTIONS BEFORE AND AFTER LICENSURE

10107.1 The Director is authorized to conduct inspections:

(a) At the time of an ALR’s application for initial licensure;

(b) Six (6) months after an ALR’s initial licensure;

(c) At the time of an ALR’s application for each annual renewal of licensure;

(d) To investigate complaints alleging a violation of the Act or this chapter; and

(e) To ensure an ALR or suspected ALR’s compliance with the Act and this chapter, at the discretion of the Director.

10107.2 The inspections set forth in § 10107.1 shall be conducted in accordance with the procedures set forth by § 306 of the Act (D.C. Official Code § 44-103.06) and D.C. Official Code § 44-505, and pursuant to the rules set forth in 22-B DCMR § 3101.

10107.3 In addition to the procedures and rules described in § 10107.2, inspections for the purpose of investigating a complaint alleging a violation of the Act or this chapter shall be guided as follows:

(a) The Director shall investigate complaint allegations of a life-threatening nature or those that represent immediate danger within twenty-four (24) hours of receipt of the complaint by the Department. All other complaints shall be investigated by the Director no later than thirty (30) days from their receipt or as deemed appropriate.

(b) The Director shall conduct complaint investigations during time periods and staff shifts consistent with the allegations in the complaint when deemed appropriate.

(c) The Director shall communicate the findings of the complaint investigation directly to the ALR or suspected ALR, and the complainant, if the complaint is received directly by the Department. If the complaint is referred by another governmental agency, the Director shall send its findings to the referring agency. The referring agency shall be responsible for communicating the findings to the complainant.

10107.4 An ALR or prospective ALR that seeks to accept the Director’s suggested remedy to a deficiency or propose its own remedy, pursuant to § 306(e) of the Act (D.C. Official Code § 44-103.06(e)), shall do so by submitting the remedy to the Director in a written, signed and dated plan of corrective action to abate the cited deficiencies. The ALR shall include the plan of corrective action in its response to the Director that is required by § 306(e) of the Act (D.C. Official Code § 44- 103.06(e)).

10107.5 The Director, after having conducted an inspection described in paragraphs (b) through (e) of § 10107.1, shall require an ALR it has determined to be in violation of the Act and the rules, but whose deficiencies are not life-threatening or seriously endangering to the public’s health, safety, and welfare, to correct the deficiencies within thirty (30) days from receipt of the written notice of violations provided by the Director pursuant to § 306(d) of the Act (D.C. Official Code § 44-103.06(d)).

10107.6 An ALR shall be subject to the sanctions provided under § 401 of the Act (D.C. Official Code § 44-104.01) if it fails to correct within thirty (30) days the deficiencies indicated in the written notice of violations provided by the Director pursuant to § 306(d) of the Act (D.C. Official Code § 44-103.06(d)) after the conclusion of any inspection conducted under § 10107.1. The Director may extend this time as he or she determines is appropriate under the circumstances.

10107.7 The Director shall, after having conducted an inspection under § 10107.1, deny, suspend, or revoke an ALR’s licensure pursuant to § 10126 of this chapter if the ALR is found to have life-threatening deficiencies or deficiencies that seriously endanger the public’s health and safety, but which do not pose an immediate threat to warrant an emergency suspension described by § 404 of the Act (D.C. Official Code § 44-104.04).

Top Takeaways:

  • 1 The Director is authorized to conduct inspections:

(a) At the time of an ALR’s application for initial licensure;

(b) Six (6) months after an ALR’s initial licensure;

(c) At the time of an ALR’s application for each annual renewal of licensure;

(d) To investigate complaints alleging a violation of the Act or this chapter; and

(e) To ensure an ALR or suspected ALR’s compliance with the Act and this chapter, at the discretion of the Director.

This essentially means the inspector can visit your facility at any time. Be prepared for their visits and open to making any changes they deem to be fit.

  • 3 In addition to the procedures and rules described in § 10107.2, inspections for the purpose of investigating a complaint alleging a violation of the Act or this chapter shall be guided as follows:
  • The Director shall investigate complaint allegations of a life-threatening nature or those that represent immediate danger within twenty-four (24) hours of receipt of the complaint by the Department. All other complaints shall be investigated by the Director no later than thirty (30) days from their receipt or as deemed appropriate.

When a resident issues a complaint with the department against your facility they will take steps to investigate the situation, especially when it comes to the matter of life safety and the welfare of residents. The inspector will relay their findings directly to the ALR when the process is complete.

 

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

 

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