Section 133.102 - Inspections(a) The Texas Health and Human Services Commission (HHSC) may conduct an inspection of each hospital prior to the issuance or renewal of a license.(1) A hospital is not subject to additional annual licensing inspections subsequent to the issuance of the initial license while the hospital maintains: (A) certification under Title XVIII of the Social Security Act, 42 United States Code (USC), §§1395 et seq.; or(B) accreditation from The Joint Commission, the American Osteopathic Association, or other national accreditation organization for the offered services.(2) HHSC may conduct an inspection of a hospital exempt from an annual licensing inspection under paragraph (1) of this subsection before issuing a renewal license to the hospital if the certification or accreditation body has not conducted an on-site inspection of the hospital in the preceding three years and HHSC determines that an inspection of the hospital by the certification or accreditation body is not scheduled within 60 days of the license expiration date.(b) HHSC may conduct an unannounced, on-site inspection of a hospital at any reasonable time, including when treatment services are provided, to inspect, investigate, or evaluate compliance with or prevent a violation of: (1) any applicable statute or rule;(2) a hospital's plan of correction;(3) an order or special order of the HHSC executive commissioner or the executive commissioner's designee;(4) a court order granting injunctive relief; or(5) for other purposes relating to regulation of the hospital.(c) An applicant or licensee, by applying for or holding a license, consents to entry and inspection of any of its hospitals by HHSC.(d) HHSC inspections to evaluate a hospital's compliance may include:(1) initial, change of ownership, or relocation inspections for the issuance of a new license;(2) inspections related to changes in status, such as new construction or changes in services, designs, or bed numbers;(3) routine inspections, which may be conducted without notice and at HHSC's discretion, or prior to renewal;(4) follow-up on-site inspections, conducted to evaluate implementation of a plan of correction for previously cited deficiencies;(5) inspections to determine if an unlicensed hospital is offering or providing, or purporting to offer or provide, treatment; and(6) entry in conjunction with any other federal, state, or local agency's entry.(e) A hospital shall cooperate with any HHSC inspection and shall permit HHSC to examine the hospital's grounds, buildings, books, records, video surveillance, and other documents and information maintained by or on behalf of the hospital, unless prohibited by law.(f) A hospital shall permit HHSC access to interview members of the governing body, personnel, and patients, including the opportunity to request a written statement.(g) A hospital shall permit HHSC to inspect and copy any requested information, unless prohibited by law. If it is necessary for HHSC to remove documents or other records from the hospital, HHSC provides a written description of the information being removed and when it is expected to be returned. HHSC makes a reasonable effort, consistent with the circumstances, to return any records removed in a timely manner.(h) Upon entry, HHSC holds an entrance conference with the hospital's designated representative to explain the nature, scope, and estimated duration of the inspection.(i) During the inspection, the HHSC representative gives the hospital representative an opportunity to submit information and evidence relevant to matters of compliance being evaluated.(j) When an inspection is complete, the HHSC representative holds an exit conference with the hospital representative to inform the hospital representative of any preliminary findings of the inspection, including possible health and safety concerns. The hospital may provide any final documentation regarding compliance during the exit conference.(k) HHSC shall maintain the confidentiality of hospital records as applicable under state or federal law. Except as provided by subsection (l) of this section, all information and materials in the possession of or obtained or compiled by HHSC in connection with an inspection are confidential and not subject to disclosure under Texas Government Code Chapter 552 (relating to Public Information), and not subject to disclosure, discovery, subpoena, or other means of legal compulsion for their release to anyone other than HHSC or its employees or agents involved in the enforcement action except that this information may be disclosed to:(1) persons involved with HHSC in the enforcement action against the hospital;(2) the hospital that is the subject of the enforcement action, or the hospital's authorized representative;(3) appropriate state or federal agencies that are authorized to inspect, survey, or investigate hospital services;(4) law enforcement agencies as allowed by law; and(5) persons engaged in bona fide research, if all individual-identifying and hospital-identifying information has been deleted.(l) The following information is subject to disclosure in accordance with Texas Government Code Chapter 552, only to the extent that all personally identifiable information of a patient or health care provider is omitted from the information: (1) a notice of the hospital's alleged violation, which must include the provisions of law the hospital is alleged to have violated, and a general statement of the nature of the alleged violation;(2) the number of investigations HHSC conducted of the hospital;(3) the pleadings in any administrative proceeding to impose a penalty against the hospital for the alleged violation;(4) the outcome of each investigation HHSC conducted of the hospital, including:(B) license denial or revocation;(C) corrective action plan adoption; or(D) administrative penalty imposition and the penalty amount;(5) a final decision, investigative report, or order issued by HHSC to address the alleged violation; and(6) any other information required by law to be disclosed under public information laws.(m) Within 90 days after the date HHSC issues a final decision, investigative report, or order to address a hospital's alleged violation, HHSC posts certain information on the HHSC website in accordance with Texas Health and Safety Code § 241.051.25 Tex. Admin. Code § 133.102
The provisions of this §133.102 adopted to be effective June 21, 2007, 32 TexReg 3587; Adopted by Texas Register, Volume 49, Number 46, November 15, 2024, TexReg 9233, eff. 11/21/2024