Failure to Provide Immediate Access for Priority One State Investigation
Penalty
Summary
The deficiency involves the facility’s failure to provide immediate access to residents for a state representative of HHSC conducting a Priority One (P1) investigation. On 03/03/2026 at 10:05 a.m., an HHSC surveyor entered the facility, checked in at the reception desk, and was taken to the conference room. At 10:11 a.m., the administrator entered the conference room and informed the surveyor that she would not be allowed into the building to conduct the P1 investigation, even after being advised that it was a P1 investigation. At 10:43 a.m., the surveyor was instructed by phone from the program manager to leave the facility. The program manager then contacted the associate regional director and briefed her on the incident. The surveyor was not allowed to re-enter and begin the entrance conference and P1 investigation until 2:00 p.m., resulting in a four-hour delay in surveyor access. During an interview on 03/03/2026 at 2:00 p.m., the administrator apologized for the situation and stated he was acting like a “ping pong ball” between corporate staff and HHSC. In a subsequent interview on 03/05/2026 at 12:30 p.m., the administrator stated the facility did not have a policy on impeding a survey or access to medical records. Review of the facility census showed there were 93 residents at the time. Review of the facility’s governing body policy indicated the governing body is responsible for establishing and implementing policies regarding management and operation of the facility. Review of state law (Health and Safety Code Ch. 242.043) and HHSC Provider Letter PL 18-26 confirmed that HHSC or its representatives may enter an institution at reasonable times to conduct inspections, surveys, or investigations and that providers must grant access to records, underscoring that the administrator’s refusal and the resulting delay were contrary to these requirements.
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