Revision 22-1; Effective February 4, 2022

In accordance with Title 40, Texas Administrative Code (TAC), Chapter 9, Subchapter D, §9.171(a), all HCS program providers must be in continuous compliance with the HCS program certification principles. (See §§9.172-9.175 and §§9.177-9.180.)

In accordance with 40 TAC, Chapter 9, Subchapter D, §9.171(d), LTCR may conduct an intermittent survey of HCS program providers at any time to ensure compliance with the HCS program certification principles.

 

 

14210 Types of Surveys

Revision 22-1; Effective February 4, 2022

LTCR conducts certification surveys of HCS program providers, at least annually, to evaluate evidence of the program provider’s compliance with certification principles.

Initial Certification Survey

After a program provider has obtained a provisional contract with HHSC, LTCR conducts an initial certification survey within 120 days after the date HHSC approves the enrollment or transfer of the first individual to receive HCS program services from the program provider under the provisional contract.

Recertification Survey

An HCS program provider's certification period is no more than 365 calendar days and must be renewed annually before the expiration of the current certification period.

The program provider must demonstrate compliance with all certification principles to be certified for another 365-day period. If the program provider is out of compliance with any certification principles, LTCR will send a final report with a list of violations to the program provider within 14 calendar days after the day of exit. The program provider must submit a plan of correction (PoC) within 14 calendar days of receipt of the report to demonstrate the actions the program provider will implement to demonstrate compliance. 

Follow-Up Survey, Vendor Hold and Denial of Certification

If LTCR determines at the end of a survey that a program provider is not in compliance with one or more of the certification principles that results in a violation, LTCR will require the program provider to develop and submit an acceptable PoC. For a critical violation, the PoC must include that corrective action will be completed within 30 calendar days after the date of the survey exit conference. An on-site follow-up survey will be conducted after the 30-day period to determine if the program provider completed the corrective action in accordance with their PoC. For a violation that is not critical, the PoC must include that corrective action will be completed within 45 calendar days after the date of the survey exit conference. An on-site follow-up survey will be conducted after the 45-day period to determine if the program provider completed the corrective action in accordance with their PoC.

If LTCR determines that the program provider has not completed the corrective action or they have failed to submit an acceptable PoC, HHSC imposes a vendor hold against the program provider or denies or terminates the certification. 

If a vendor hold is imposed for a program provider with a provisional contract, HHSC will initiate termination of the program provider's contract in accordance with Texas Administrative Code (TAC) §49.534, Termination of Contract by HHSC.

If a vendor hold is imposed for a program provider with a standard contract, LTCR will conduct a survey at least 31 calendar days after the effective date of the vendor hold to determine if the program provider completed the corrective action required to release the vendor hold. If the program provider completed the corrective action, HHSC will release the vendor hold. If the program provider has not completed the corrective action, HHSC will deny or terminate the certification.

See 40 TAC, Chapter 9, Subchapter D, §9.183, Program Provider Compliance and Corrective Action.

Intermittent Surveys

Intermittent surveys are always unannounced and conducted at the discretion of LTCR. These surveys are based on:

  • complaints;
  • follow up to abuse, neglect or exploitation (ANE) allegations;
  • deaths;
  • ANE Trending Report; 
  • residential visits; or
  • internal HHSC referrals.

 

 

14220 Overview of the Home and Community-based Services Certification Survey Process

Revision 22-1; Effective February 4, 2022

LTCR may conduct unannounced certification surveys or on-site visits at any time.

When the survey team lead contacts the HCS program provider of an upcoming initial certification or recertification survey, the team lead will send a copy of the Provider Information Request form to the program provider.

The team lead will also send Form 8576, Individual Profile Information, to the HCS program provider with a date for the information to be completed and returned to the survey team lead.

Entrance Conference

At the beginning of every initial or recertification survey, the LTCR survey team will conduct an entrance conference with the program provider and any program staff who are present. The LTCR survey team lead will explain the survey process.

The survey team will review a sample of 10% or more of the individuals in the HCS program provider's contract. The team uses standardized checklists to ensure that all principles are reviewed for compliance. These checklists can be found on the HCS Provider Portal. 

Certification survey activities include, but are not limited to:

  • interviewing individuals, family members, Legally Authorized Representatives (LARs), service providers and staff;
  • visiting residences and day habilitation sites;
  • reviewing individuals' records (including medical records);
  • reviewing personnel and staff training records;
  • reviewing financial records of the individuals for which the program provider handles finances;
  • reviewing complaint information, satisfaction surveys and Consumer Advocate Advisory Committee (CAAC) meeting minutes;
  • reviewing information regarding any deaths, discharges (permanent or temporary) and allegations of abuse, neglect and exploitation;
  • reviewing fire drills and emergency evacuation plans, as well as four-person residence approvals and fire marshal inspections for four-person residences; and
  • reviewing critical incident data, restraints and restrictive behavior support plans.

The survey team will hold a final debriefing at the end of the survey. The program provider is allowed to submit evidence to show compliance prior to the exit conference. 

Exit Conference

LTCR conducts an exit conference at the end of all surveys, at a time and location determined by HHSC. LTCR gives the program provider a written statement of concern, Form 3701, Preliminary Findings Based on Survey, Inspection or Investigation, at the exit conference.

Note: If the survey team identifies an immediate threat, the program provider is expected to immediately provide the survey team with a plan of removal. If the immediate threat cannot be eliminated, HHSC will deny certification and coordinate with the local intellectual and developmental disability authority (LIDDA) for the immediate provision of alternative services for the individuals.

Informal Dispute Resolution

If a program provider disagrees with the survey results, they may request an informal dispute resolution (IDR). The IDR process is an informal process by which a program provider can dispute, before an independent third party, the findings on which a violation is based. The outcome of the IDR serves as the independent third party’s recommendation to HHSC regarding the program provider’s compliance or noncompliance with program rules. Information about the IDR process is found in Provider Letter 2021-07. 

Note: The program provider must still submit an acceptable PoC no later than 14 calendar days after receiving Form 3724, Statement of Licensing Violations and Plan of Correction, from HHSC even if the program provider chooses to use the IDR process.

 

 

14230 Plan of Correction (PoC)

Revision 22-1; Effective February 4, 2022

Within 14 calendar days after receiving the final survey report, the program provider must submit a PoC to address each violation that was identified during the survey. This applies even if the provider disagrees with the findings of violations or requests an informal dispute resolution (IDR). 

For violations that are critical, the PoC must include the corrective action(s) the program provider will take for each violation. The PoC must also have a completion date within 30 calendar days from the survey exit date. 

For violations that are noncritical, the PoC must include the corrective action(s) the program provider will take for each violation. The PoC must have a completion date within 45 calendar days from the survey exit date. HHSC will review the PoC and the program provider will be notified in writing whether the plan has been approved or denied. If the plan is denied, the program provider must submit a revised plan within five business days of request for a revised PoC. Once the plan is approved, HHSC will request that the program provider submit evidence of the correction to HHSC and HHSC may conduct a follow-up survey to verify the corrections.