Here is an example of a violation containing all three components. Each component is labeled.

Regulatory Reference

Z222 558.249(c), Self-Reported Incidents of Abuse, Neglect, and Exploitation

If an agency has cause to believe that a client served by the agency has been abused, neglected, or exploited by an agency employee, the agency must report the information immediately, meaning within 24 hours, to:

(1) the Department of Family and Protective Services (DFPS) at 1-800-252-5400, or through the DFPS secure website at www.txabusehotline.org; and

(2) HHSC Complaint and Incident Intake (CII) at 1-800-458-9858.

Deficient Practice Statement

This requirement was not met as evidenced by:

Based on record review and interview, the agency failed to report an incident of exploitation immediately to HHSC at 1-800-458-9858 and the Department of Family and Protective Services (DFPS) at 1-800-252-5400 for Client #1.

Relevant Findings

The findings included:

• Review of the complaint intake form for incident #12345 identified that the agency reported an incident of exploitation for Client #1 to HHS on 6/8/19. Review of the provider investigation report dated 6/8/19 indicated the agency received the allegation on 4/20/19 but did not report the incident to HHS until 6/8/19, approximately six weeks later. Review of the DFPS confirmation report indicated that the agency reported the incident to DFPS on 6/8/19. The agency failed to report the incident immediately to HHSC and TDFPS as required.
• On 7/18/19 at 2:05 PM, the Administrator verified that the allegation was received on 4/20/19 and that the incident was not reported to HHSC or DFPS until 6/8/19.