Preparing for an Inspection

Licensure Rules

Prescribed Pediatric Extended Care Centers

(PPECCs)

Long-term Care Regulation

Health and Human Services Commission

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 Learning Objectives

The information contained in this Computer Based Training (CBT) focuses on PPECC licensure rules. You will learn information about the rules allowing you to evaluate the conditions, staffing, quality of care, general operations, policies and procedures at your center.

In this course you will:

• Examine PPECC licensure rule requirements
• Evaluate your overall compliance using the questions posed in this CBT
• Review actions you can take to prepare for an inspection

 Introduction

This CBT was designed for those who provide PPECC services and Health and Human Services Commission (HHSC) survey staff.

The presentation guides you through the rules in conjunction with self-assessment questions which will assist you in preparing for an inspection. They are meant to provide a starting place to evaluate your center. As you read through the CBT think about the policy and procedures you have in place. You can compare your daily practices to the rules to determine if you are in compliance.

Licensure Rules 

Title 26 Part 1 Chapter 550 of the TAC are the key rules affecting PPECCs. The rules are divided into Subchapters A-G. This CBT will focus on Subchapter C which includes the nine divisions listed below:

 Please download a copy of these rules while reviewing this CBT. Using the website of the Texas Secretary of State (SOS), a person may request of copy of a rule chapter or subchapter from the TAC. The SOS will email a link to the requestor that can be used to download a document containing the requested rules. See Provider Letter 19-02 to request Title 26, Part 1, Chapter 550.

 Division 1: Operations and Safety Provisions

The operations and safety rules are included in this division. You are required to have policies which impact the goods and services that you provide. As you read the rules, you will see the phrase "adopt and enforce" as it relates to policy. When you prepare for an inspection, you should review how the policy is being implemented. If you see that the policy either fails to address all the requirements or that staff may be failing to implement the required tasks, you should take immediate corrective action. Below are the rules located in Division 1.

 Operations

The overall operations of your center including hours, suspension of operations, business records and billing are key areas that must follow certain guidelines described in the rules. You should prepare for an inspection by reviewing both your policy and practices. Once you review your policy and practices, you should compare your findings to the rules. Below are questions you may want to consider when preparing for an inspection.

§550.201 Operating hours

• Do you have operating hours posted?
• Do you have a policy for operating hours?
• How will you inform the public and those you serve if you are closed?

 §550.202 Suspension of Operations

• Do you have a policy to notify parents when you will suspend operations?
• Does the policy include a 30-day prior notification?
• Do you have a policy in place that includes start and stop dates, how to obtain records and discharge planning?

§550.203 Financial Solvency and Business Records

• Do you have all of your contracts with outside vendors up to date?
• Are all of your business records accurate, dated and each entry in its original state without correction tape or fluid?

 §550.204 Billing and Insurance Claims

• Do you have a policy that includes procedures for submitting billing?
• Are there safeguards in your policy that prevents, detects and reports fraud, waste and abuse?

 Safety Provisions

According to §550.205, you must have certain safety provisions in place including any applicable requirements related to the 2000 edition of the LSC of the National Fire Protection Association (NFPA) and the requirements in Subchapter E of this chapter (relating to Building Requirements). The administrator and nursing director must participate in monthly fire drills and must review the fire drill plan for effectiveness and document any corrective action.

Prior to the inspection or anytime throughout the year, verify you are following the safety provisions in the rules which includes having the following:

• Annual fire inspection report by a fire marshal
• Fire drill plan
• Monthly fire drill report on the HHSC Fire Drill Report form
• Fire drill evaluations and corrective action
• Landline/satellite telephones with emergency numbers
• Policies and procedures for a medical emergency
• First aid kit
• Policies and procedures for the verification and monitoring of visitors
• Policies and procedures for releasing a minor
• Policies and procedures that specify no minor is left unattended at the center
• Childproof electrical outlets/covers
• Safety precautions for strings and cords
• Safety precautions for all play material that is not permanently attached
• Equipment is safe and free from sharp or rough edges and toxic paints
• Policies describing a weapons-free location
• Policy for the prohibition of the use of tobacco in any form
• Policy on the prohibition of alcohol, illegal substances and toxic substances

 Person-Centered Direction and Guidance

A person-centered approach is where the person is placed at the center of the service and treated as a person first. The focus is on the person and what they can do, not their condition or disability. Support should focus on achieving the person's aspirations and be tailored to their needs and unique circumstances. According to §550.206, you must have a person-centered policy on the direction and guidance by individuals providing services to minors. This policy must be implemented and integrated into a system-wide approach through the use of a committee. Person-centered direction and guidance must be individualized and consistent for each minor. Each minor must be addressed based on their particular needs and level of behavior. The minor's functional and educational level of development must be considered when addressing their behavior.

When preparing for an inspection or reviewing overall compliance, you should ensure that person-centered approaches are integrated in the following areas:

• Teaching of behavior coping skills
• Proactive strategies to identify and manage behavior
• Monitoring and evaluation of behavior management
• Procedures for consistency of language, practices and application
• Strategies that encourage self-control
• Processes that promote positive behavior
• Practices that prevent negative discipline
• Appropriate use of quiet time
• Protections from harsh, cruel or unusual treatment
• Appropriate individuals who serve on committees
• Training, collaboration, education of parents, staff, volunteers and contractors

 Protective Devices and Restraints

A protective device is a mechanism or treatment, including sedation, that is used for body positioning to immobilize a minor during a medical, dental, diagnostic, or nursing procedure, to permit wounds to heal or for a medical condition diagnosed by a physician, and not used as a restraint to modify or control behavior. A restraint can be chemical, physical or mechanical. Restraints restrict the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior. A restraint must not be used for controlling a minor's behavior in a non-emergency, staff convenience, coercion or retaliation, or as part of a behavior component of a minor's psychosocial program. According to §550.207, protective devices must have a physicians order each time they are used and are never to be used pro re nata (PRN) or as-needed basis.

Review areas such as training and procedures to verify the following practices are in place for the use of protective devices:

• Consent is always given by the adult minor or a minor's parent and in the plan of care.
• Devices are used only as part of the therapeutic regimen, and to protect the minor.
• Physician's order indicates the circumstances of use, instruction, duration and less restrictive measures.
• RN, with input from the IDT, conducted an assessment for the ongoing need for a protective device.
• Staff are properly trained in the device's application.
• RN assessed the minor during application no less than once every hour with devices removed.
• Documentation occurs in the medical record, at least every 180 days, or as the minor's needs change.

Restraints must only be used in a emergency when the immediate health and safety of any minor is at risk. When you prepare for an inspection ensure that chemical or mechanical restraints are not used routinely. Remember, restraints must not obstruct a minor's airway, impair breathing; interfere with communication, extend muscle groups away from each other, use hyperextension of joints or use pressure points or pain. All staff who apply restraints must have training. The RN must also assess the minor who was restrained three days post restraint and make any changes or updates to the plan of care. You must ensure all the appropriate documentation occurs along with notification of the physician and parent within the specified time periods.

 Equipment, Devices and Supplies

According to §550.208, you are required to ensure all equipment, devices and supplies meet the needs of the minors and this also includes for emergency purposes. You must coordinate with the minor, parents, physician or other basic providers to ensure these items are available at the center.

Below are questions you may want to consider when preparing for an inspection and to ensure continual compliance with the rules found in §550.208.

• Are consumable supplies and resources, including diapers available as needed?
• Do you ensure the equipment, devices, and supplies are inspected for safety purposes and maintained at least annually or more frequently if recommended by the manufacturer?
• Is the equipment maintained free of defects or anything that could pose a potential hazard to a minor or an individual at the center?
• Do you ensure that the equipment used by a minor is cleaned and sanitized after each use?
• Do you have a clean storage area for equipment, devices and supplies?

 Emergency Preparedness Planning and Implementation

According to §550.209, you must have an emergency response plan. Verify that your plan includes the following:

• Individual approaches to different emergency situations
• Evaluation 30 days after each emergency and annually
• Risk assessment of potential emergencies
• Description of minors served, and the type of assistance needed
• Eight core functions of emergency management

You must have a fire emergency response plan which is available to all staff. Verify the following types of trainings have occurred and you have the documentation to support compliance:

• Use and response of alarms
• Isolation and extinguishment of fire
• Evacuation
• Notification procedures
• Monthly drills
• Relocation

 Sanitation, Housekeeping and Linens

Sanitation is defined as protection from illness, the transmission of disease or loss of life due to unclean surroundings, the presence of disease transmitting insects or rodents, unhealthful conditions or practices in the preparation of food and beverage or the care of personal belongings. Improper sanitation may indicate other failures, such as a lack of oversight or lack of staffing to ensure the center is clean. You are to ensure the proper sanitation occurs inside and outside the center. You must ensure the center meets all the requirements in §550.210.

Below are questions you may want to consider when preparing for an inspection and to ensure continual compliance with the rules for sanitation, housekeeping and linens:

• Do you have pest control?
• Do you properly dispose of trash in the correct containers?
• Are your grounds well-kept?
• Are the interior surfaces free from hazards?
• Are your storage areas clean and organized?
• Do you have a written work plan for housekeeping operations?
• Are supplies including chemicals stored in a safe place?
• Is there a designated staff person to oversee housekeeping?
• Do you have enough clean linens at all times to meet the needs of minors?
• Are linens handled, stored and processed so as to control the spread of infection?
• Are linens maintained in good repair?
• Are linens washed, properly stored, and transported using universal precautions?
• Are linens and cleaning separated from food preparation or storage?

 Infection Prevention and Control Program

According to §550.211, you must have an infection prevention and control program (IPCP). Under the IPCP, the center must investigate, prevent and control infections. The program must address isolation procedures such as an isolation room, vaccinations and documentation addressing incidents and corrective actions.

You should verify that your IPCP plan includes the following information, and the center is implementing the program:

• Identification of at-risk minors
• Notification and reporting procedures
• Prevention of infectious individuals to have direct contact with minors or food
• Handwashing occurs at all the required times
• Training to use Personal Protective Equipment (PPE)
• Designated crib, bed or mat for each minor's exclusive use each day
• Supplies such liquid soap, disposable paper towels and trash containers at each sink
• Procedures for an identified public health disaster
• Reassessment of the risk classification must be conducted for any exposures
• System to screen all individuals providing services at the center
• Positive results of an infectious disease referred to the person's personal physician
• Protection from vaccine preventable diseases, in accordance with THSC, Chapter 224

 Summary of Actions to Prepare for an Inspection

The safe functioning of the center depends upon qualified trained staff making conscious decisions to safeguard the safety of minors. Division 1 of Subchapter C contain key elements designed for the minor's safety and well-being. The actions and processes you implement are keys in maintaining compliance with rules.

Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Tour the center and observe the overall condition of the building to determine if the center has safety hazards and proper emergency equipment. Are the staff trained and do they understand the procedures to ensure the safety of the minors?
• Review the policies that impact person-centered guidance. Is there a focus on how the center manages, treats and provides guidance to staff during episodes of behavior?
• Review both the policy and processes for protective devices and restraints. Does the center document incidents when these devices are used and what corrective actions are taken after a device or restraint has been applied?
• Review the policy and procedures for the emergency plan and fire plan. Do staff understand the eight core functions and the fire emergency plan?
• Sanitation and housekeeping accompanied by an effective infection control plan should be evident within the center. Are items stored, cleaned and sanitized?
• Review your process for screening infectious disease. Have there been any outbreaks of disease and what corrective action have you taken? Are staff practicing universal precautions?

 Division 2: Administration and Management

According to §550.301, the license holder is responsible for the conduct of the center and for the adoption, implementation and enforcement of the written policies. Is there someone designated in writing who meets the qualifications and conditions to serve as the administrator and alternate?

Is there a written description of the center's organizational structure? The document must include the center's organization structure and lines of authority, the governing body, board of directors, the administrator/alternate, the medical director, the nursing director/alternate, advisory committee, interdisciplinary team (IDT), staff and the lines of authority and the delegation of responsibility down to and including the direct care level according to §550.302.

 Administrations and Management

Review the following functions or records to verify all those in administration meet the qualifications and carry out their duties as described in the rules:

• Does the administrator/alternate's personnel file reveal the required qualifications? (See §550.303)
• Does the administrator supervise the operations for all services to minors on a day-to-day basis? (See §550.304)
• Has the administrator/alternate completed the required training? (See §550.305 - §550.306)
• Does the center have a designated medical director (MD) who has a valid, unrestricted license? (See §550.307)
• Is the MD available in person or by phone during the center's operating hours? (See §550.307)
• Is the MD involved in the Quality Assurance Performance Improvement (QAPI) program? (See §550.308)
• Does the nursing director/alternate's personnel file reveal he/she meets the qualifications? (See §550.309)
• Does the nursing director supervise or coordinate the plan of care, staffing, documentation, census, ratio and other operational facets of the medical needs of the minors? (See §550.310)

 Summary of Actions to Prepare for an Inspection

Your center must have a well-qualified management team to ensure the health and safety of the minors are protected. Prior to an inspection or before making any hiring decision, review an individual's qualifications or personnel files to verify that each individual has all the required qualifications and training. In addition, you should make observations of the interactions of the management team with staff and the minors. You should verify if the management team is actively involved in all phases of operations.

 Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Verify the administrator/alternate (hired within the last 12 months), had no enforcement actions at the previous center.
• Conduct routine background checks to verify staff do not have a disqualification due to a conviction or offense.
• Verify the administrator only manages one center.
• Verify the administrator's routine/actions indicate he/she is clearly involved in the day-to-day operations of the center.
• Verify that management ensures the correct ratio of staff is present at all times based on census.
• Ensure management was aware of all incidents and provided protection to the minors and provided notifications.
• Verify documentation occurs at every level of the operation.
• Review the record to verify if the parent satisfaction surveys were distributed and evaluated.
• Verify that the center adheres to all policies including the clinical operations of the center.
• Verify that there is ongoing timely staff evaluations and job performance reviews occur.

 Division 3: Nursing and Staffing

This division addresses the requirements and qualifications for licensed and unlicensed staff. You must implement policies that comply with the rules of the Texas Board of Nursing. (See §550.407). In certain instances, nurses may delegate certain tasks to unlicensed personnel specified in 22 TAC Chapter 224. You should ensure that the nursing ratio, at a minimum is at no time less than one qualified staff member on duty per three minors. If only one qualified staff member is on duty, that member must be an RN. The staffing ratio is based on the number of minors on the center's actual census. A center must maintain documentation that support compliance per §550.410.

This section also includes:

 Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs)

Verify all RNs and LVNs have met the qualification requirements under (§550.402 and §550.404) and if they are meeting their responsibilities under (§550.403 and §550.405).

Below are questions you may want to consider when preparing for an inspection or when monitoring your center for compliance:

• Do you have documentation of current licenses?
• Do nurses have certification in cardiopulmonary resuscitation (CPR)?
• Do nurses have training in basic first aid?
• Do staff have the required experience?
• Do you have a policy that requires RNs meet competency requirements?
• Do all RNs follow the standards for delegation?
• Are RNs and LVNs involved in the implementation of the plan of care?
• Are the RNs coordinating services?
• Do the RNs and LVNs have knowledge of community resources?
• Do the RNs and LVNs participate in the IDT meetings?
• Do the RNs and LVNs who are administering medications documenting?
• Do you have supervising nursing who monitor services?
• Do you have documentation of communication with ancillary therapies?
• Are nurses communicating the status of minors to the physician?

 Student Nurses

You may have student nurses working at a center. If so, you must ensure the center is in compliance with §550.406. You will need to verify the following to ensure you are ready for an inspection:

• Is there a written contract with an accredited school of nursing?
• Are there criminal history checks for student nurses?
• Have you ensured that student nurses are not counted in the ratio?
• Are the students supervised by a qualified onsite instructor?
• Is an RN assigned to no more than three students at a time?
• Are you maintaining a ratio of RNs to census?
• Are you ensuring students are not performing care beyond their training?

 Direct Care Staff

A center may employ unlicensed direct care staff. According to §550.409, direct care staff must meet certain qualifications and the center must enforce a policy for these qualifications.

Below are questions you may want to consider when preparing for an inspection or monitoring your center for compliance:

• Are all the direct care staff 18 years of age or older?
• Do all staff have a high school diploma or a general equivalency degree?
• Do staff have current certification in pediatric CPR and basic first aid?

Do each of the staff have one of the following:

• One year of experience employed in a health care setting providing direct care to minors?
• Two years of experience employed in a health care, childcare or school setting providing direct care to minors?
• Two years of experience employed in a health care setting providing direct care to adults?
• Skills to meet the competency and training requirements?

 Rehabilitative and Ancillary Professional Staff

According to §550.411,all rehabilitative and ancillary professional staff must have one year of experience of pediatric care in a health care setting. A rehabilitative professional providing services or supervising services at a center must be supervised by a center's qualified licensed person who practices under the center's policies and procedures. None of these individuals can be considered in the staffing ratio.

If you employ any of these staff, you must verify if they meet the qualifications:

• Audiologist with a valid license under Texas Occupations Code (TOC), Chapter 401
• Occupational therapist (OT) or assistant with a valid license under TOC, Chapter 454
• Physical therapist (PT) or assistant with a valid license under TOC, Chapter 453
• Respiratory therapist (RT) with a valid license under TOC, Chapter 604
• Social worker (SW) with a valid license under TOC, Chapter 505
• Qualified dietitian who has a valid license under the laws of the State of Texas
• Registered dietitian with one year of supervisory experience in dietetic service
• Pharmacist with a valid license under TOC, Chapter 558
• Speech-language pathologist (SLP) or assistant with a valid license under TOC, Chapter 401

 Contractors

According to §550.413, if a center uses contractors, you must enter into a contract with each contractor. The contract must be enforced and clearly designate the following:

• Minors are accepted for care only by the center
• Types of the services provided including per visit or per hour
• Compliance with policy and staff qualifications
• Participation in the plan of care
• Coordination and evaluation of services
• Conforming to standards of documentation and record keeping

You are not required to maintain a personnel record for contractors. Upon request by HHSC, you must provide documentation at the site of a survey no later than eight working hours of the request to demonstrate that contractors meet the center's written job qualifications for the position and duties performed and in compliance with §15.418 relating to Criminal History Checks, Nurse Aide Registry (NAR) and Employee Misconduct Registry (EMR) Requirements.

 Volunteers

To prepare for an inspection related to volunteers (§550.414), you should review the following:

• Do volunteers have defined roles and supervision?
• Does each volunteer meet the same qualifications, requirements and standards that apply to center staff performing the same activities on behalf of the center?
• Are you including volunteers in the staffing ratios? (This should not occur)

 Personnel Requirements

According to §550.415, you must have staffing policies and procedures that govern all staff providing services including employees, volunteers and contractors. These polices and procedure include orientation, criminal history checks, immunizations, infectious diseases, competency and training, employee development and job training. According to §550.419, if you conduct drug testing, the written policy must describe the method by which drug testing is conducted. If you do not practice drug testing, the written policy must state that the center does not conduct drug testing. You must provide a copy of the policy to anyone applying for services from the center and any person who requests a copy of the policy.

According to §550.416, you must have a quarterly staff development program. Verify the development program includes the following:

• Participation of staff, minor and parents in the IDT process
• Communication skills
• Education of childhood illness
• Development of case management skills to assist parents at home
• Preparation for a disaster and lifesaving skills
• Teach coping skills and behavior management skills
• Basic life support certification

According to §550.417, personnel records must include the following:

• Signed job description
• Required qualifications
• Job Application
• Record of the immunization's
• Verification of references
• Applicants job experience
• Education licenses, permits, and certifications
• Annual performance evaluations
• Disciplinary actions

 Criminal History

According to §550.418, Criminal History Checks, NAR and EMR checks must be conducted for applicants and employees including a volunteer or contractor (See §550.413).

Verify if criminal history checks were conducted and all individuals met Texas Health and Safety Code (THSC) Chapter 250. Before you hire an applicant search the NAR and the EMR using the HHSC website to determine if an applicant or employee is listed in either registry as unemployable.

In addition to the initial verification of employability, you must search the NAR and the EMR to determine if the employee is listed as unemployable in either registry at least every 12 months. You must immediately discharge the employee's criminal history check reveals a conviction of a crime that bars employment.

 Summary of Actions to Prepare for an Inspection

This division focuses on the requirements for various staff which include RNs, LVNs, student nurses, OTs, PTs, SWs, SLPs, pharmacists, dieticians, direct care staff, contractors and volunteers. Routine training and verification of competency related to the type of care should be an ongoing function. Those involved in the ancillary services who have assistants should ensure proper supervision is occurring and documentation of the care provided is occurring.

 Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Verify all licenses
• Ensure that each discipline is involved in the IDT and plan of care
• Review medication administration to ensure it follows the Board of Nursing rules
• Verify that volunteers have assigned roles and have been trained
• Verify the proper checks have been completed for criminal history, EMR and NAR
• Review personnel files to ensure that all the required information is present
• Review the staff development program such as when it occurs and the subject matter
• Verify the staffing ratio is correct
• Verify that contractors are integrated into the systems of the center
• Verify that all direct staff are qualified, trained and evaluated

 Division 4: Basic Services

According to §550.501, you must ensure the provision of all basic services based on the needs of a minor and a minor's family in accordance with the plan of care. These services include medical, nursing, psychosocial, social, rehabilitative, developmental and nutrition. In this section we will review what the requirements include and how they provide overall support for the needs of the minor. All services are provided in relation to ongoing assessments of the minors needs then implemented through the use of the plan of care.

Below are the rules located in Division 4.

 Medical and Nursing Services

You must ensure that you only admit minors who are medically dependent or technologically dependent. This is defined as the condition of an individual who, because of an acute, chronic, or intermittent medically complex or fragile condition or disability, requires ongoing, technology-based skilled nursing care prescribed by a physician to avert death or further disability, or the routine use of a medical device to compensate for a deficit in a life-sustaining body function. The term does not include a controlled or occasional medical condition that does not require continuous nursing care, including asthma or diabetes, or a condition that requires an epinephrine injection.

Below are questions you may want to consider when preparing for an inspection:

§550.502 Medical Services

• Do you ensure the minor's physician maintains responsibility for the overall plan and collaborates with the staff providing services?
• Does the nursing director communicate with each physician at least every 90 days or more frequently when the minor has a change in condition?
• Do you have a written policy that requires therapists consult with a minor's prescribing physician directly or coordinate with the clinical staff at least every 180 days or more frequently when there is a health status or physical status change in a minor's condition?

§550.503 Nursing Services

• Are nursing services provided as described in the plan of care and as ordered by a physician?
• Does the nursing director/designee participate in pre-admission planning and maintain responsibility for monitoring care and treatment?
• Does the nursing director participate in the IDT, ensure documentation occurs and provide parental instruction?

 Psychosocial Treatment and Services

Psychosocial treatment is the provision of skilled services to a minor under the direction of a physician that includes assessment of alterations in mental status or evidence of suicide ideation or tendencies, teaching coping mechanisms or skills, counseling activities or evaluation of a plan of care.

Below are questions you may want to consider when preparing for an inspection:

§550.504 Psychosocial Treatment and Services

• Are psychosocial treatments overseen by a physician, RN or psychologist as described in the plan of care?
• Are written policies and procedures relating to the provision of psychosocial treatments include interventions to foster normal development, person-centered direction and guidance and including use of restraints?
• Do the initial health assessments include mental status, behavioral status, sensory and motor function, cranial nerve function, language function and any other criteria established by the center's policy?

 Social Services

Social services are those actions designed to promote the minor's well-being. Social services include being involved in the IDT, advocating for the minor and participating in the development of the plan of care.

Below are questions you may want to consider when preparing for an inspection:

§550.505 Social Services

• Are social services being provided as described in the plan of care and as ordered by a physician?
• Are social services overseen by a social worker or RN that actively participates in the coordination of care, interdisciplinary comprehensive assessments and plan of care?
• Do the minor's parents receive assistance in finding appropriate local community resources and assistance to enhance coping skills?

 Rehabilitative Services

These services may include physical therapy, occupational therapy, speech and language therapy, cognitive therapy, and mental health rehabilitation services. Rehabilitation services promote adaptations, emphasize abilities, treat the whole person, educate and should offer person centered care. These services could be preventative, restorative, supportive or palliative.

Below are questions you may want to consider when preparing for an inspection:

§550.506 Rehabilitative Services

• Are rehabilitative services as described in the plan of care provided as ordered by a physician?
• Are rehabilitative services overseen by a licensed or certified qualified professional staff as specified in §550.411?
• Do all individuals who provide rehabilitative services actively participate in the coordination of a minor's care and the ongoing IDT comprehensive assessments?

 Developmental Services

The developmental delay of any part of a minor's abilities must be referred to Early Childhood Intervention Services . Early intervention means identifying and providing effective early support to children and young people who are at risk of poor outcomes. Effective early intervention works to prevent problems from occurring, or to tackle them head-on when they do before problems get worse.

Below are questions you may want to consider when preparing for an inspection:

§550.507 Functional Developmental Services

• Are functional developmental services as described in the plan of care and as ordered by a physician provided?
• Are minors referred to Early Childhood Intervention Services within seven days after identification of a developmental delay or risk of developmental delay in accordance with Code of Federal Regulations, Title 34, §303.303?
• Are all functional assessments incorporated into the comprehensive assessment to include developmentally appropriate areas for each minor?

§550.508 Educational Developmental Services

• Do you enforce written policies and procedures to facilitate each minor's access to available early intervention and educational services and programs in the least restrictive environment in the community?
• Is the educational policy person-centered, parent driven and collaborative with the educational provider?
• If education occurs onsite, is it done so in collaboration with a minor's parent and a minor's prescribing physician in accordance with the LEA's Admission, Review, and Dismissal (ARD) committee or committee required by Section 504 of the Rehabilitation Act of 1973?

 Parent Training

The involvement of a minor's parent plays a critical role in the overall well-being of the minor. Each part of the center's care should include a segment which provides training and support for the parent to transfer those skills in the home environment. Parents can provide key information on their overall satisfaction and give you details on how the center is training and being supportive of their goals.

Below are questions you may want to consider when preparing for an inspection:

§550.509 Parent Training

• Does parent training occur for each minor's parent and family as identified in a minor's plan of care and is it documented?
• Have you identified the minimum frequency for parent training and if the training includes the importance of basic life support certification and first aid training?
• Does the training program facilitate parent participation in the IDT in the development of an individualized comprehensive plan of care and emergency medical plan?
• Does the plan improve communication, collaborative relationships and provide mechanisms and skills for coping with the effects of childhood illness?
• Does the training include dietary counseling, coping with behavior and skills in the use of any technology?

 Nutritional Counseling

According to §550.510, the center must provide nutritional counseling. This includes a advising and assisting an adult minor or a minor's parent or family on appropriate nutritional intake by integrating information from a nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention and nutrition education.

Below are questions you may want to consider when preparing for an inspection:

• Do you provide training on the exercise habits, food budget and problems with food preparation?
• Do you counsel on the dietary needs of each minor?
• Do you provide education to inform parents why certain foods should be included or excluded to help with adjustment to any new, revised or existing diet plan?
• Are there written diet plans as ordered by the minor's physician, to include instructions for implementation?
• Do you provide motivation to appreciate the importance of the diet plan in getting and staying healthy?
• Do you recommend ideas for meal planning, food budget planning and appropriate food gifts?

 Dietary Services

The center must have written policy and procedures to ensure minors receive a diet as recommended by the American Academy of Pediatrics or Food and Nutrition Board of the National Research Council, National Academy of Sciences or a diet ordered by a minor's prescribing physician. If meals and snacks are supplied by an adult minor or a minor's parent, the center's written policy and procedures must include a written signed agreement between the center and the adult minor or minor's parent. This agreement must include what occurs if the parents are unable to provide the required meal plan or snacks ordered by the physician. In cases where the parent provides the meals the dietician would not be responsible.

Below are questions you may want to consider about dietary services, when preparing for an inspection:

§550.511 Dietary Services

• Is the dietitian responsible for the overall dietary needs of the minor?
• Does the dietitian participate in conferences with the IDT?
• Does the dietitian review the plan of care for any known food allergy and monitor any special diet ordered by a physician?
• Are menus prepared at least one week in advance, written for each type of diet and vary from week to week?
• Is the current week's menu posted in a conspicuous location and then retained for 30 days?
• Do the tables allow minors to eat together?
• Do staff help minors who use adaptive equipment?
• Is food served on appropriate tableware and are clean napkins, bibs, dishes and utensils available?
• Are food intakes recorded of all minors?
• Do minors go more than three hours without a meal or snack being offered?
• Is the food stored, prepared, and served under sanitary conditions?
• Is garbage and refuse properly disposed of?

 Summary of Actions to Prepare for an Inspection

Division 4 describes the various types of service. It is important to understand the philosophy of person-centered care in relation to these services. The adult minor, the minor and the minor's parent should be integrated into the overall implementation of these services.

Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Review dietary services including meal services, menus, adaptive equipment, diets and orders, snacks, food preparation and sanitation.
• Ensure parents have received training in the case management of the needs of the minor, use of adaptive equipment, dietary counseling, behavior coping skills, basic first aid, cardiopulmonary resuscitation, emergency medical plan and other types of skills necessary to provide home care.
• Ensure you have methods to identify developmental delays and if the process includes how to make the necessary referrals.
• Verify the center collaborates and integrates both functional and educational aspects of care into the minor's care.
• Review the interdisciplinary team to ensure it consists of the required qualified disciplines actively participating in the development of the plan of care.
• Verify that all types of services that were identified in the comprehensive assessment are being delivered as dictated by the physician and plan of care.

 Division 5: Admissions, Assessments, Plan of Care and Discharge or Transfer

This division contains the requirements for admissions. According to §550.601, the prescribing physician, in consultation with the minor's parent and the minor, take into consideration the medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, education and development needs of the minor in addition to the emotional, psychosocial and environmental factors. Once this is done the referral may be processed and a pre-admission conference occurs. After the admission process has been completed the IDT will conduct a comprehensive assessment and develop a plan of care.

Below are the rules located in Division 5:

 Admissions

According to §550.602, before an admission can occur, a pre-admission conference must be scheduled by the nursing director. This conference must be completed no later than three days after receiving a referral. According to §550.604, you must conduct an interview with a minor's parent or an adult minor before or at a minor's admission that addresses the center's policy, nutrition guidelines, basic services, transportation, emergency procedures, infection control, discharge and other information.

Key steps to prepare your center for an inspection include the following actions:

§550.603 Agreement and Disclosure

• Verify the written agreement and disclosure form was provided to the minor's parent or with the adult minor before services are provided which includes an attestation the parents have legal authority for consent. This document must include specific information.

§550.604 Admission Procedures

• Ensure all admissions interviews are conducted timely .
• Verify that a copy of a minor's medical history and physical (H&P) examination dated 30 days before or after the date of the minor's admission is on file.
• Verify that a signed order from the minor's prescribing physician on the day of the minor's admission is in the record.

 Assessments and Plan of Care

According to §550.605, an initial assessment must be conducted no earlier than three business days before admission. The comprehensive assessment must be conducted by an RN and identify the minor's medical needs, discharge plans, parent training needs and any coordination of services that are required. According to §550.606, the RN must be a part of the IDT. The IDT must monitor these services and conduct ongoing assessments. Once the assessment is completed the IDT and RN must develop and implement the plan of care. The RN, a minor's parent and adult minor, must sign the plan of care within five days after initiation of the plan and the prescribing physician must review and sign the plan of care within 30 days after initiation of the plan.

Below are questions you may want to consider when preparing for an inspection:

§550.605 Initial and Updated Comprehensive Assessment

• Did the assessment identify all medical, psychosocial, therapeutic, nutritional, functional or educational needs?
• Was the comprehensive assessment conducted at least once every 180 days or after a change of condition?

§550.606 Interdisciplinary Team

• Do the designated IDT members monitor services and implement the plan of care?
• Does the IDT prepare a written plan of care as described in §550.607, that includes discharge planning?

§550.607 Initial and Updated Plan of Care

• Does the plan of care include measurable goals with achievable time frames and evaluations of the interventions?
• Is the plan of care in the record no later than 10 days after receiving the signed plan from the physician?
• Are copies of the plan of care given to all appropriate individuals in a language the recipient understands?
• Did a review or update occur of the plan of care at least every 180 days, or for a change in condition?
• Does the center have written policies and procedures regarding the coordination of the plan of care?

 Discharge or Transfer

You may transfer or discharge a minor without providing the oral and written notification for the following reasons:

• Minor's parent or adult minor request a transfer or discharge
• Medical emergency
• Health and safety risks are imminent
• Protection of the minor
• Failure to pay

To prepare for an inspection, consider taking the following action:

§550.608 Discharge or Transfer Notification

• Verify that all minors who were transferred or discharged have received the proper notification. This notification should go to the adult minor, parent and physician. The notification should be both oral and written and be provided no later than 15 days before the date of transfer or discharge.

 Summary of Actions to Prepare for an Inspection

You have now reviewed all the requirements for Division 5. This division includes information on the admission process and the requirements to admit a minor. Once admitted the center must immediately conduct an initial assessment and comprehensive assessment. These assessments provide details about the minor's current condition and level of needs. These assessments must be conducted on an ongoing basis as the minor's needs change. You must develop a plan of care through the collaboration of the IDT. The members of the IDT should include representatives who are providing the type of care the minor needs but must include an RN who is responsible for the implementation of the plan of care.

Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Determine if the time frames were met for the initial assessment after a referral from the physician.
• Verify the disclosure form contains all the required information and was provided to all appropriate individuals.
• Verify the medical record contains the H&P and the date that was placed in the chart should indicate 30 days before or after admission.
• Verify the assessment reflects the actual condition of the minor and if any change of conditions occurred.
• Determine if the interventions were evaluated and assessed by the IDT.
• Determine if the plan of care was completed timely and if needed updated within the appropriate time frames or when a change of condition occurred.
• Verify the center has policies that describe the IDT and the coordination of care that must occur and how they are to communicate and collaborate with all the required individuals.
• Verify if the center provided the appropriate 15-day notification for discharges.

 Division 6: Physician, Pharmacy, Medication and Laboratory Services

This division contains the requirements for physician orders. According to §550.701, minors who are admitted must remain under the care of the physician. Physician orders must include all applicable services which might include nursing services, medication administration, dietary needs, activities, therapies or transportation authorization. According to §550.702, you must have a written policy describing protocols and procedures regarding physician orders which comply with THSC Chapter 248A and all applicable state and federal regulations. The written policy must address who may obtain an order, when it is to be signed by the licensed staff and physician and the time frames for signature.

Below are the rules located in Division 6.

 Medication and Pharmacist Services

Medication and pharmacy services are an important aspect of ensuring the health and safety of minors. According to §550.703, if you administer or store medications, you must have a pharmacist or a qualified RN to provide consultation to management. These individuals should provide guidance and consultation by reviewing medical records to ensure that the medication records are accurate and updated, in-service training to staff on the storage and administration of medications and ensuring pharmaceutical compliance. You must have policies and procedure which include labeling, control, storage, integrity, control and accountability for medications. Medications requiring refrigeration must be kept in a separate locked box in a separate refrigerator from the refrigerator the center uses to store food.

Below are questions you may want to consider regarding medication and pharmacist services, when preparing for an inspection:

§550.703 Pharmacist Services

• Does the pharmacist or RN consult on written policies and procedures?
• Does consultation and in-service training occur for the storage and administration of medications?

§550.704 Storage of Medication

• Does proper labeling, storage, integrity, control and accountability occur of all medications?
• Are over the counter (OTC) medications stored separately and labeled correctly?
• Are medications in a locked cabinet with Schedule II substances kept under two locks?

§550.705 Administration of Medication

• Does an RN review the medication list initially upon admission and is it updated when needed or at least every 90 days?
• Are significant findings from any reviews of the medication list reported to the physician?
• Do you have a policy that ensures medication errors or adverse reactions are reported?
• Are there policies and procedures that include certain processes?

 Disposal of Medical Waste or Pharmaceuticals

According to §550.707, you must adopt and enforce a written policy for the safe handling and disposal of special or medical waste and materials, including bio-hazardous waste and materials.

To prepare for an inspection, consider taking the following actions:

§550.707 Disposal of Special or Medical Waste

• Verify the center disposes of the waste according to the requirements issued by the Department of State Health Services in 25 TAC Chapter 1, Subchapter K (relating to Definition, Treatment and Disposition of Special Waste from Health Care-Related Facilities).

§550.708 Disposal and Destruction of Pharmaceuticals

• Determine if the center has a written policy for the safe and legal disposal and destruction of pharmaceuticals in accordance with all state, federal and local laws.

 Summary of Actions to Prepare for an Inspection

You have now reviewed all the requirements for Division 6. This division includes information on the required process to obtain physician orders. This section also provides the requirements for the medication including administration, storage and disposal.

Key steps to prepare your center for an inspection and to maintain compliance include conducting the following actions:

• Verify the center has a written policy for the safe and legal disposal and destruction of pharmaceuticals.
• Determine if an RN reviews the medication list at least every 90 days or sooner if there are changes.
• Verify that all significant changes were reported to the physician and family.
• Verify all orders have a physician signature and the orders encompass all services that are being provided.
• Verify that medications are stored under a lock and that schedule II medications are double locked.
• Determine if medications which are stored in refrigeration are locked and stored in a separate refrigerator from the food.
• Review documentation from the pharmacist or the qualified RN to determine if the center is obtaining in-service training and other pharmaceutical services that comply with the rules.

 Division 7: Care Policies, Coordinations of Services and Census

This division contains the requirements for care policies, coordination of services and census. According to §550.801, you must adopt and enforce written policies and procedures that specify the center's care practices. You must have policies and practices that address assessments, admissions, transfers, discharges, attendance, active play, safety, nursing care, abuse neglect and exploitation, person-centered guidance, restraints, teaching, care planning, palliative care, medication administration and emergency plans of care.

Below are the rules located in Division 7.

 Care Policies, Coordinations of Services and Census

Care coordination involves deliberately organizing minor care activities and sharing information among all of the participants concerned with a minor's care to achieve safer and more effective care. According to §550.803, you must have written policies and procedures that address the census. This policy must address developing, maintaining, retrieval and the staff responsible for the census lists.

Below are questions you may want to consider when preparing for an inspection:

§550.802 Coordination of Services

• Does an effective exchange of information and reporting among all staff providing services occur?
• Does the documentation demonstrate the coordination of services?

§550.803 Census

• Do you have a daily and total census list?
• Does the list include the minor's name, services, who is responsible, time the minor entered and left the center and other identifying information about the minor?

 Summary of Actions to Prepare for an Inspection

This division includes the requirements for you to ensure that the coordination of care occurs over a broad range of services. You should not duplicate services nor should certain aspects of care be overlooked or "fall through the cracks." When preparing for an inspection, it is critical to review each assessment and verify all the services are being provided. Also ensure these services are effective, consistent, and monitored on an ongoing basis.

Key steps to prepare your center for an inspection and to maintain compliance you should conduct the following actions:

• Determine if services are provided as assessed
• Verify the census list contains all the required information
• Determine if you follow the rules as described in §550.801, by coordinating care and services in areas that include:

• assessments
• admissions
• transfers
• discharges
• attendance
• active play
• safety
• nursing care
• person-centered guidance
• restraints
• teaching
• care planning
• palliative care
• medication administration
• emergency plans of care

 Division 8: Rights and Responsibilities, ANE, Investigations, Reporting and Inspection Results

This division contains the requirements for rights and responsibilities, abuse neglect and exploitation (ANE) reporting and inspection results. According to §550.901, you must adopt and enforce written policies and procedures to ensure a minor's legal rights are observed and protected.

Below are the rules located in Division 8.

 Rights and Responsibilities

According to §550.901, you must ensure the rights and responsibilities are communicated to the parent and minor. The communication must occur both orally and in writing in a language they understand. You must obtain the signature of the adult minor and minor's parent to confirm that the individual received the notice. These rights include being informed about the types of services they will be receiving and any changes in those services.

Below are questions you may want to consider when preparing for an inspection:

§550.901 Rights and Responsibilities

• Is there documentation of the notification for rights and responsibilities?
• Do you ensure the minor is free from ANE?
• Do the minor and parents know how to report ANE and how to make a complaint?
• Is there a time frame to resolve complaints?
• Are minors discriminated against or suffer retaliation?
• Are minors treated their age and allowed to interact with other minors?
• Are minors or parents informed in advance of who will provide services and the frequency of services, changes in the plan of care, expected outcomes and limitations, information how to participate in planning of services, advance directives, confidentiality, availability of support groups or other programs?

 Advance Directives

According to §550.902, You must provide information to parents and minors regarding the Advance Directives Act, THSC, Chapter 166.

Below are questions you may want to consider when preparing for an inspection:

§550.902 Advance Directives

• Have you adopted and enforced a written policy regarding implementation of advance directives?
• Were parents and minors provided information regarding advance directives?
• Does your policy include a clear and precise statement of any procedure the center is unwilling or unable to provide or withhold in accordance with an advance directive?

 Abuse, Neglect and Exploitation

HHSC investigates a complaint or an incident of abuse, neglect, or exploitation when the act occurs at a center, a center employee is responsible for the care of a minor at the time the act occurs, or the alleged perpetrator is associated with the center. A complaint of abuse, neglect, or exploitation that does not meet these criteria must be referred to the Department of Family and Protective Services.

Below are questions you may want to consider when preparing for an inspection:

§550.903 Abuse, Neglect, or Exploitation Reportable to HHSC

• Have you adopted and are you enforcing a written policy relating to procedures for preventing, detecting, reporting alleged acts of abuse, neglect and exploitation of a minor?
• If any suspected ANE occurred, was it reported immediately to HHSC and appropriate law enforcement agencies with all the required information?
• Are all written reports of any investigation sent to the HHSC Complaint Intake Unit no later than five days after the initial report?
• Do employees sign a statement indicating that the employee may be criminally liable for the failure to report abuse, neglect or exploitation?
• Do you prominently and conspicuously post a readable sign for display in a public area accessible to minors, minors' parents, employees and visitors that reads: "Cases of Suspected Abuse, Neglect, or Exploitation Shall be Reported to HHSC by calling 1-800-458-9858?"

 Investigations

According to §550.904, HHSC investigates a complaint of non-compliance with THSC Chapter 248A or Chapter 550 regarding treatment or care, and/or a lack of respect for a minor's property by anyone furnishing services at the center. You must not retaliate against any person for filing a complaint, presenting a grievance, or providing good faith information relating to services provided by a center. A center is not prohibited from terminating an employee for a reason other than retaliation. You must not discharge or otherwise retaliate against a minor or a minor's parent for presenting a complaint or grievance.

Below are questions you may want to consider when preparing for an inspection:

§550.904 Investigations of a Complaint and Grievance

• Have you adopted and do you enforce a written policy relating to procedures for prompt investigation of complaints, grievances and reports of ANE?
• Do you acknowledge receipt of any documents, complaints and grievances?
• Do you initiate an investigation no later than 10 days after receiving a complaint or grievance?
• Do you document all components of the investigation?
• Do you retain all investigation documentation for a minimum of three years from the date a complaint or grievance was received?

 Death Reporting and Inspection Results

Below are questions you may want to consider when preparing for an inspection:

§550.905 Reporting of a Minor's Death

• Have you reported to HHSC the death of any minor and those minors transferred from the center to a hospital who expired within 24 hours after the transfer?
• Did you submit to the HHSC Consumer Rights and Services section a HHSC Provider Investigation Incident Report form no later than 10 days after the date of a minor death?

§550.906 Examination of Inspection Results

• Are the inspection results available? Have you redacted from the report any information that is confidential under state or federal law?

 Summary of Actions to Prepare for an Inspection

You must ensure that the rights and responsibilities are explained, and that minors and parents have a signed copy. You must report and investigate ANE. You are responsible to protect the health and safety of minors during an investigation. If ANE occurs outside of the center's services and not connected to any staff member the center must refer that to DFPS.

Key steps to prepare your center for an inspection and to maintain compliance you should conduct the following actions:

• Verify the inspection results have been made available.
• Determine if all deaths have been reported within the timeframe.
• Review complaints and grievances, then determine if the center investigated the concern, made all the proper reports and notifications.
• Review the advance directives of minors and or the lack of directive, then determine if the center provided all the required notification.
• Verify the center has a policy for advance directives.
• Verify the center has a policy on rights and responsibilities.
• Review the process the center uses when ANE is discovered. Determine if the center has procedures for preventing, detecting, reporting alleged acts of abuse, neglect and exploitation of a minor.

 Division 9: Medical Records, QAPI, Dissolution and Retention of Records

This division contains the requirements for medical records and the structure and purpose of the quality assessment and performance improvement (QAPI) committee. According to §550.1001, you must establish and maintain a medical record system to ensure that the services provided to a minor are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information. The QAPI program provides a method to ensure ongoing compliance with the rules by identifying issues or concerns that lead to noncompliance.

Below are the rules located in Division 9.

 Medical Records

There must be a single file for services provided to a minor and a minor's parent. The medical records policy should include information regarding the use and removal of records, security, safeguarding the records, alteration, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the medical record. You must not use correction fluid or tape in the record. Corrections are made by striking through the error with a single line and including the date the correction was made and the initials of the person making the correction. You must ensure that all progress notes are written the day service is rendered and incorporated into the medical record no later than two business days after the services are rendered.

Key steps to prepare your center for an inspection and to maintain compliance you should conduct the following action:

§550.1001 Medical Records

Verify the medical record includes the following information:

• Referral and application for services
• Name, address and telephone number of a minor's parent, or others as identified by a minor's parent
• Physician's name and telephone numbers, and an emergency contact number and signed orders
• Comprehensive assessments, medical history including allergies and special precautions and subsequent assessments
• Plans of care, nursing care plans and other plans as applicable
• Nutritional counseling and special diets, as appropriate
• Clinical and progress notes from all professionals providing services to a minor
• Medication list, medication administration record, if medication is administered by center staff
• Immunization record
• Acknowledgment relating to Rights and Responsibilities and receipt of the policy for reporting ANE
• Acknowledgement of receipt of the notice of advance directives
• Acknowledgement of receipt of the center's policies relating to discipline and guidance
• Documentation of how to register a complaint
• Discharge summary
• Services provided to a minor's parent

 QAPI

According to §550.1002, the QAPI program must evaluate all services including monitoring and evaluating the quality of services, improving measurable outcomes and resolving identified concerns. The program must include the frequency and detail of data collection. The data must be collected at least quarterly for all services provided to a minor. The program must include a system that measures the quality, effectiveness, and safety of services and identifies opportunities and priorities for performance improvement.

Key steps to prepare your center for an inspection and to maintain compliance you should conduct the following actions:

§550.1002 Quality Assessment and Performance Improvement

• Verify the center has developed, implemented and maintains an ongoing QAPI program.
• Verify the center has designated in writing the group or individuals, by title, responsible for the QAPI program.
• Verify the center's QAPI Committee meets quarterly or more often if needed to analyze the data collected and to use the data to improve services.
• Determine if the QAPI committee is comprised of specific persons based on the services provided at the center.

 Dissolution and Retention of Records

Below are questions you may want to consider when preparing for an inspection:

§550.1003 Dissolution

• Do you have a written policy that describes a written contingency plan for dissolution?
• Does this plan include procedures to notify minors or parents of the dissolution and to transfer or discharge minors consistent with §15.608?

§550.1004 Retention of Records

• Do you have a written policy relating to the retention of records?
• Do you retain all original medical records until a minor's twenty-fourth birthday or five years from the date of service, whichever is later?

Summary of Actions to Prepare for an Inspection

You have now completed your review of the rules found in this division. This division requires the center to have a structure in place to safeguard the medical information of the minors. The content of the medical records should contain all the documentation from the services the minor is receiving. You must ensure you review the policy for medical records, and it contains all the requirements in the rules. The retention of records has certain time frames unless there is ongoing litigation in which case the center must retain the records until the litigation is resolved. This section also contains the requirements for the center to have a QAPI committee. The function of this committee is to identify patterns, trends or concerns which need monitoring or intervention to maintain compliance with the rules and to achieve a better quality of care for the minors.

Key steps to prepare your center for an inspection and to maintain compliance you should conduct the following actions:

• Verify a policy exists for the required timeframes for the retention of records.
• Review your plan for the dissolution of the business and if that plan provides for the safe discharge and or transfer of the minors.
• Evaluate your QAPI program to ensure it meets quarterly and provides an ongoing assessment of your services.
• Verify the center has designated in writing the group or individuals, by title, responsible for the QAPI program.
• Verify that clinical and progress notes are written the day service is rendered and incorporated into the medical record no later than two business days after the services are rendered.
• Verify all the required contents are located in the medical record.

 Conclusion

You may use the information in this CBT to formulate a strategy to review key center operations. You can also develop a list of records needed for an inspection.

You should maintain on ongoing review of your systems, policies and procedures. When corrective action is needed you can use your QAPI committee to assist in monitoring those corrections.

Please feel free to review this CBT each year.

If you have additional question you may contact:

• LTCRPolicy@hhs.texas.gov
• LTCRJointTraining@hhs.texas.gov
• LTCR-FieldOperations@hhs.texas.gov

Other helpful resources can be located at these sites:

• HHS Texas.gov
• HHSC Long Term Care Providers
• HHSC Contact Us
• Sign up for Texas HHS e-mail and text updates
• Texas.gov