Assisted Living Operators across Texas understand the need to be ready and prepared for inspectors to walk in the doors at any time. It’s no secret going through an inspection can be stressful for the team. This post is intended to help ease that stress by providing a few handy tips to help the team prepare.
Let’s start with, what are inspectors looking for when they enter a community?
What are inspectors looking for when they enter a community?
According to the Texas Health & Human Services website they are looking for the following:
During an inspection, the inspectors assess the facility’s:
➤ compliance with residents’ rights requirements;
➤ compliance with residents’ quality of life requirements;
➤ compliance with residents’ quality of care requirements;
➤ accuracy of residents’ comprehensive assessments;
➤ adequacy of plans of care based on comprehensive assessments;
➤ effectiveness of the physical environment to empower residents, accommodate their needs, and maintain their safety.
Inspectors are trained to see that resident dignity and quality of life is being maintained. In addition, they must ensure an environment is safe.
Top 10 deficiencies
Texas Health & Human Services last published in July of 2018 it’s Top 10 Deficiencies, sharing data from 2017. To say the least, this data is dated and much has changed within the department since.
The Texas Department of Aging and Disability Services (TDADS) sunsetted and Texas Assisted Living regulation fell onto Texas Health and Human Services Commission (HHSC). Nonetheless, the data is out there with the majority of the list Life Safety related. Below is a quick recap and link for your convenience.
New Access Route to Texas Licensing Standards for Assisted Living Facilities
If you are having difficulty finding the Texas Licensing Standards for Assisted Living Facilities, they have moved to the Texas Secretary of State website under a new Title of the Texas Administrative Code. Here is a direct link, or you can find a ‘printer friendly’ version provided by Texas Assisted Living Association on their website at this link.
Texas Administrative Code (TAC) Title 26 Health & Human Services, Part 1 Texas Health & Human Services Commission, Chapter 553, Licensing Standards for Assisted Living Facilities (effective 5/6/2019)
➤ THSC, Title 4, Chapter 253: Employee Misconduct Registry;
➤ THSC, Title 4, Chapter 247: ALFs; and
➤ THSC, Title 4, Chapter 250: Nurse Aide Registry and Criminal History Checks of Employees and Applicants for Employment in Certain Facilities of Employees and Applicants for Employment in Certain Facilities Serving the Elderly Persons with Disabilities.
Policies and Documents Handy
Many inspectors will request a tour upon arriving. The tour can help set a positive tone for the inspection and is an opportunity for the community to shine by demonstrating residents are happy, safe and well cared for! In addition, the tour can check of a few items on an inspectors list such as required postings upon entrance, posted menus and activity calendars, food establishment permit (if applicable), life safety checklist items, and more. Frequently tour your community with the eyes of an inspector and ensure these items are kept current.
So what policies/documents should you have handy? In most cases, inspectors will request a few standard items. However these lists can vary from region to region. Below are key documents to have handy should an inspector request them:
Please note, this list is NOT all inclusive but a guide based on experience of what main items to have immediately available upon an inspectors request.
- Current Resident Roster with room numbers
- Current Staff Roster including titles and hire dates
- Copy of Current Assisted Living Facility License & Certification for Alzheimer’s Facility, if applicable
- Tour Packet – including copy of Current Disclosure Statement handed out to prospective residents and/or families
- Move In Packet – including copy of a Resident Agreement and all required documents a community must provide a resident at time of move in. 553.41(d) & (e)
- Abuse Neglect & Exploitation Policy 553.102(a-f)
- Advanced Directives Policy 553.41 (g)(2)
- Smoking Policy 553.62(c)(3)
- Accident, Injury, Acute Illness Policies 553.41(k)
- Resident Comprehensive Assessment and screening forms 553.41(c)
- Medication Policies 553.41(j)
- Personnel Policies: 553.41(i)
- including exclusions for hiring, criminal history checks, misconduct and nurse registry checks, TB testing, vaccination policy, and statement of employee liability for reporting abuse, neglect and exploitation, etc.
- Manager Designation Letter 553.41(a)(1)(E)
- Key Leadership training & qualifications (suggest have personnel files handy)
- Staff Training: 553.41(a)(4) including orientation content schedule and continuing education content schedule
- Infection Control Policies 553.41(n)
- including: infection control, biohazard waste, communicable disease reportable and control of policies, vaccination policies (553.41(r)(1-3), universal precautions, and soiled linens
- Life Safety Items:
- Emergency Preparedness Disaster & Evacuation Plan
- Fire Drills 553.62(c)(2)
- Physical Plant Contracts such as pest control, fire & Sprinkler systems, generator, hood vents, and more. Include proof of routine inspection documents as applicable
- Posted Menus
- Activity Calendars
- Recent survey results
- Recent reportable incidents with investigation and final details
- Recent Accidents, Injury Reports with outcomes noted
- Grievance Log
- For Certified Alzheimer’s Facility: refer to 553.51 for additional specific training and programing requirements
Depending on the type of survey, inspectors may chose to follow staff on duty, interview residents, staff and/or family members, and review resident and personnel records. Keep current these files ensuring documents are filed and in compliance. Audit departments frequently and train team members about an inspection process.
In summary, aiming to be survey ready everyday can help to ease the stress of an inspection. Be prepared, know what may be requested and conduct frequent Mock Surveys to prepare your team for an inspection.
Below are links to local resources! Stay tuned and sign up with Texas HHSC for Provider Letters. There are frequent updates that come through and new rules that affect a community.
For additional support on preparing a community for an inspection, reach out to us at RevealSol. We are here to help!
- ➤ 1 HHSC – Webinar Trainings: Top 10 Deficiencies – https://apps.hhs.texas.gov/business/CBT/deficiences/alf-2017/TOP_TEN_ALF_0713201811.html
- ➤ Texas Administrative Code Title 26, Part 1, Chapter 553: https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=4&ti=26&pt=1&ch=553
- ➤ Texas HHSC – Provider Trainings: https://apps.hhs.texas.gov/providers/training/jointtraining.cfm
- ➤ Subscribe to Texas HHSC Provider Letter updates via email: https://hhs.texas.gov/doing-business-hhs/provider-portals/long-termcare-providers
- ➤ Texas HHSC – New Regional Boundaries: https://hhs.texas.gov/about-hhs/communications-events/news/2019/10/new-regionalboundaries-long-term-care-regulatory-services
- ➤ Texas Assisted Living Association (www.TALA.org) – printable version of Texas Licensing Standards for Assisted Living: https://tala.org/wp-content/uploads/2019/05/REG-Updates-Combined-5-21-19.pdf
Disclaimer: The content found here in Industry Insights is created by RevealSol, LLC and in the opinion of the writer and not all inclusive of senior living operational considerations