10.07.05.07

.07 Inspection by the Department.

A. Residential Service Agency to be Open for Inspection.

(1) The Department or its designee may conduct announced or unannounced licensure inspections or complaint investigations to ensure compliance with the requirements of this chapter.

(2) The agency shall be open for inspection by the Department during all hours identified in the agency’s application as routine business hours.

B. Access to Agency and Sites Where Services Are Offered. Upon the request of the Department, an agency shall:

(1) Make its offices available for inspection during other than its routine business hours;

(2) Assist the Department in gaining access to sites where services are provided for the purpose of conducting inspections to:

(a) Ensure that the agency is in compliance with the regulations of this chapter; and

(b) Enable the Department to investigate and resolve complaints filed against the agency.

C. Records and Reports.

(1) Inspection.

(a) A licensee shall maintain records and reports to support compliance with the regulations of this chapter. All records and reports shall be open to inspection by the Department.

(b) Except for the records permitted to be stored off site, a licensee or licensee’s designee shall immediately, upon request, provide copies of records and reports, including medical records of clients, to the Department. The Department shall, if requested, reimburse the licensee for the cost of copying records and reports.

(2) Maintenance.

(a) The residential service agency shall maintain files on site pertaining to:

(i) Current clients;

(ii) Clients that have been discharged within the last 12 months;

(iii) Current staff;

(iv) Staff that have been discharged within the last year; and

(v) Quality assurance activities.

(b) All other records may be stored off site, but shall be available for inspection within 24 hours of the Department’s request.

D. An agency shall make available upon request to clients, client representatives, potential clients, or federal, State, or local regulatory or law enforcement agencies any statements of deficiencies, reports, and plans of corrections.

E. Notice of Violations.

(1) If a complaint investigation or survey inspection identifies a regulatory violation, the Secretary shall issue a notice:

(a) Citing the violation or deficiency;

(b) Requiring the residential service agency to submit an acceptable plan of correction within 10 calendar days of receipt of the notice of violation or deficiency;

(c) Advising the residential service agency that failure to correct cited violations or deficiencies may result in sanctions; and

(d) Offering the residential service agency the opportunity for an informal dispute resolution conference (IDR).

(2) The plan of correction referred to in §E(1)(b) of this regulation shall include the date by which the licensee shall complete the correction of each deficiency. Failure to return an acceptable plan of correction within the allotted timeframe may result in a sanction.

(3) When a licensee requests an IDR as provided in §F of this regulation, the licensee shall file a plan of correction within the required time, except to the extent that the licensee contests specific findings. If the licensee contests specific findings, absent the Department’s directive, a licensee may delay submitting its plan of correction with respect to those specific findings until 5 days after the licensee is provided oral or written notice of the outcome of the IDR.

F. Informal Dispute Resolution (IDR).

(1) A licensee may request an informal dispute resolution conference (IDR) to question violations or deficiencies within 10 days of receiving the statement of deficiencies. The written request for an IDR shall fully describe the disagreement with the statement of deficiencies and be accompanied by any supporting documentation.

(2) At the discretion of the Office of Health Care Quality, the IDR may be held in person, by telephone, or in writing. In-person IDRs are informal in nature and are not attended by counsel.

(3) The IDR process may not delay the effective date of any enforcement action.