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RULE §9.178 Certification Principles: Quality Assurance


Published: 2015

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(a) In the provision of HCS Program services to an
individual, the program provider must promote the active and maximum
cooperation with generic service agencies, non-HCS Program service
providers, and advocates or other actively involved persons.
(b) The program provider must ensure personalized service
delivery based upon the choices made by each individual or LAR and
those choices that are available to persons without an intellectual
disability or other disability.
(c) Before providing services to an individual in a
residence in which host home/companion care, supervised living, or
residential support is provided, and annually thereafter, the program
provider must:
  (1) conduct an on-site inspection to ensure that, based
on the individual's needs, the environment is healthy, comfortable,
safe, appropriate, and typical of other residences in the community,
suited for the individual's abilities, and is in compliance with applicable
federal, state, and local regulations for the community in which the
individual lives;
  (2) ensure that the service coordinator is provided
with a copy of the results of the on-site inspection within five calendar
days after completing the inspection;
  (3) complete any action identified in the on-site inspection
for a residence in which supervised living or residential support
will be provided to ensure that the residence meets the needs of the
individual; and
  (4) ensure completion of any action identified in the
on-site inspection for a residence in which host home/companion care
will be provided to ensure that the residence meets the needs of the
individual.
(d) The program provider must ensure that:
  (1) emergency plans are maintained in each residence
in which host home/companion care, supervised living or residential
support is provided;
  (2) the emergency plans address relevant emergencies
appropriate for the type of service, geographic location, and the
individuals living in the residence;
  (3) the individuals and service providers follow the
plans during drills and actual emergencies; and
  (4) documentation of drills and responses to actual
emergencies are maintained in each residence.
(e) A program provider must comply with the requirements
in this subsection regarding a four-person residence.
  (1) Before providing residential support in a four-person
residence, the program provider must:
    (A) ensure that the four-person residence meets one
of the following:
      (i) is certified by:
        (I) the local fire safety authority having jurisdiction
in the location of the residence as being in compliance with the applicable
portions of the National Fire Protection Association 101: Life Safety
Code (Life Safety Code) as determined by the local fire safety authority;

        (II) the local fire safety authority having jurisdiction
in the location of the residence as being in compliance with the applicable
portions of the International Fire Code (IFC) as determined by the
local fire safety authority; or
        (III) the Texas State Fire Marshal's Office as being
in compliance with the applicable portions of the Life Safety Code
as determined by the Texas State Fire Marshal's Office; or
      (ii) as described in paragraph (2) of this subsection,
is certified by DADS as being in compliance with the portions of the
Life Safety Code applicable to small residential board and care facilities
and most recently adopted by the Texas State Fire Marshal's Office;
and
    (B) obtain DADS approval of the residence in accordance
with §9.188 of this subchapter (relating to DADS Approval of
Residences).
  (2) DADS inspects for certification as described in
paragraph (1)(A)(ii) of this subsection only if the program provider
submits to DADS Architectural Unit:
    (A) one of the following:
      (i) if the four-person residence is located in a jurisdiction
with a local fire safety authority:
        (I) a completed DADS Form 5606 available at www.dads.state.tx.us
documenting that the local fire safety authority having jurisdiction
refused to inspect for certification using the code (i.e. the Life
Safety Code or IFC) for that jurisdiction; and
        (II) written documentation from the Texas State Fire
Marshal's Office that it refused to inspect for certification using
the Life Safety Code; or
      (ii) if the four-person residence is located in a jurisdiction
without a local fire safety authority, written documentation from
the Texas State Fire Marshal's Office that it refused to inspect for
certification using the Life Safety Code; and
    (B) a completed DADS form "Request for Life Safety
Inspection-HCS Four-Person Home" available at www.dads.state.tx.us.
  (3) The program provider must:
    (A) obtain the certification required by paragraph
(1)(A) of this subsection annually; and
    (B) ensure that a four-person residence:
      (i) contains a copy of the most recent inspection of
the residence by the local fire safety authority, Texas State Fire
Marshal's Office, or DADS; and
      (ii) is in continuous compliance with all applicable
local building codes and ordinances and state and federal laws, rules,
and regulations.
(f) The program provider must establish an ongoing
consumer/advocate advisory committee composed of individuals, LARs,
community representatives, and family members that meets at least
quarterly. The committee:
  (1) at least annually, reviews the information provided
to the committee by the program provider in accordance with subsection
(p)(6) of this section; and
  (2) based on the information reviewed, makes recommendations
to the program provider for improvements to the processes and operations
of the program provider.
(g) The program provider must make available all records,
reports, and other information related to the delivery of HCS Program
services as requested by DADS, other authorized agencies, or CMS and
deliver such items, as requested, to a specified location.
(h) The program provider must conduct, at least annually,
a satisfaction survey of individuals and LARs and take action regarding
any areas of dissatisfaction.
(i) The program provider must comply with §49.309
of this title (relating to Complaint Process).
(j) The program provider must:
  (1) ensure that the individual and LAR are informed
of how to report allegations of abuse, neglect, or exploitation to
DFPS and are provided with the DFPS toll-free telephone number (1-800-647-7418)
in writing;
  (2) comply with §49.310(4) of this title (relating
to Abuse, Neglect, and Exploitation Allegations); and
  (3) ensure that all staff members, service providers,
and volunteers:
    (A) are instructed to report to DFPS immediately, but
not later than one hour after having knowledge or suspicion, that
an individual has been or is being abused, neglected, or exploited;
    (B) are provided with the DFPS toll-free telephone
number (1-800-647-7418) in writing; and
    (C) comply with §49.310(3)(B) of this title.
(k) If the program provider suspects an individual
has been or is being abused, neglected, or exploited or is notified
of an allegation of abuse, neglect, or exploitation, the program provider
must take necessary actions to secure the safety of the individual,
including:
  (1) obtaining immediate and ongoing medical or psychological
services for the individual as necessary;
  (2) if necessary, restricting access by the alleged
perpetrator of the abuse, neglect, or exploitation to the individual
or other individuals pending investigation of the allegation; and
  (3) notifying, as soon as possible but no later than
24 hours after the program provider reports or is notified of an allegation,
the individual, the individual's LAR, and the service coordinator
of the allegation report and the actions that have been or will be
taken.
(l) Staff members, service providers, and volunteers
must cooperate with the DFPS investigation of an allegation of abuse,
neglect, or exploitation, including:
  (1) providing complete access to all HCS Program service
sites owned, operated, or controlled by the program provider;
  (2) providing complete access to individuals and program
provider personnel;
  (3) providing access to all records pertinent to the
investigation of the allegation; and
  (4) preserving and protecting any evidence related
to the allegation in accordance with DFPS instructions.
(m) The program provider must:
  (1) promptly, but not later than five calendar days
after the program provider's receipt of a DFPS investigation report:
    (A) notify the individual, the LAR, and the service
coordinator of:
      (i) the investigation finding; and
      (ii) the corrective action taken by the program provider
in response to the DFPS investigation; and
    (B) notify the individual or LAR of:
      (i) the process to appeal the investigation finding
as described in Chapter 711, Subchapter M of this title (relating
to Requesting an Appeal if You are the Reporter, Alleged Victim, Legal
Guardian, or with Disability Rights Texas); and
      (ii) the process for requesting a copy of the investigative
report from the program provider;
  (2) report to DADS in accordance with DADS instructions
the program provider's response to the DFPS investigation that involves
a staff member or service provider within 14 calendar days after the
program provider's receipt of the investigation report; and
  (3) upon request of the individual or LAR, provide
to the individual or LAR a copy of the DFPS investigative report after
concealing any information that would reveal the identity of the reporter
or of any individual who is not the alleged victim.
(n) If abuse, neglect, or exploitation is confirmed
by the DFPS investigation, the program provider must take appropriate
action to prevent the reoccurrence of abuse, neglect or exploitation,
including, when warranted, disciplinary action against or termination
of the employment of a staff member confirmed by the DFPS investigation
to have committed abuse, neglect, and exploitation.
(o) In all respite facilities and all residences in
which a service provider of residential assistance or the program
provider hold a property interest, the program provider must post
in a conspicuous location:
  (1) the name, address, and telephone number of the
program provider;
  (2) the effective date of the contract; and
  (3) the name of the legal entity named on the contract.
(p) At least annually, the program provider must:
  (1) evaluate information about the satisfaction of
individuals and LARs with the program provider's services and identify
program process improvements to increase the satisfaction;
  (2) review complaints, as described in §49.309
of this title, and identify program process improvements to reduce
the filing of complaints;
  (3) review incidents of abuse, neglect, or exploitation
and identify program process improvements that will prevent the reoccurrence
of such incidents and improve service delivery;
  (4) review the reasons for terminating HCS Program
services and identify any related need for program process improvements;

  (5) evaluate critical incident data described in subsection
(y) of this section and compare its use of restraint to aggregate
data provided by DADS at www.dads.state.tx.us and identify program
process improvements that will prevent the reoccurrence of restraints
and improve service delivery;
  (6) provide all information the program provider reviewed,
evaluated, and created as described in paragraphs (1) - (5) of this
subsection to the consumer/advocate advisory committee required by
subsection (f) of this section;
  (7) implement any program process improvements identified
by the program provider in accordance with this subsection; and
  (8) review recommendations made by the consumer/advocate
advisory committee as described in subsection (f)(2) of this section
and implement the recommendations approved by the program provider.
(q) The program provider must ensure that all personal
information concerning an individual, such as lists of names, addresses,
and records obtained by the program provider is kept confidential,
that the use or disclosure of such information and records is limited
to purposes directly connected with the administration of the program
provider's HCS Program, and is otherwise neither directly nor indirectly
used or disclosed unless the consent of the individual to whom the
information applies or his or her LAR is obtained beforehand.
(r) The program provider must comply with this subsection
regarding charges against an individual's personal funds.
  (1) The program provider must, in accordance with this
paragraph, collect a monthly amount for room from an individual who
lives in a three-person or four-person residence. The cost for room
must consist only of:
Cont'd...