10.07.14.11

.11 Investigation by Department.

A. Assisted Living Program to Be Open for Inspection.

(1) An assisted living program operated by a licensee, and any premises proposed to be operated as an assisted living program, shall be open at all times to announced or unannounced inspections by the Department and by any agency designated by the Department.

(2) Any part of the facility, and any surrounding accessory buildings which may be entered by staff or residents, are considered part of the facility and are subject to inspection.

B. Records and Reports.

(1) Inspection.

(a) A licensee shall maintain records and make reports as required by the Department. The records and reports shall be open to inspection by the Department or its designee.

(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 residents, to the Department or its designee. The Department or its designee shall, if requested, reimburse the licensee for the cost of copying the records and reports.

(2) Maintenance.

(a) The assisted living program shall maintain files on-site pertaining to:

(i) Current residents;

(ii) Residents who have been discharged within the last 6 months;

(iii) Staff; and

(iv) Quality assurance activities.

(b) These files listed in §B(2)(a) of this regulation shall be maintained on-site where residents are being cared for.

(c) All other records may be stored off-site, but shall be available for inspection within 24 hours of the Department's request or request of the Department's designee.

C. An assisted living program shall post the following documents in a conspicuous place that is visible to residents, potential residents, and other interested parties:

(1) All of the following:

(a) Any statement of deficiencies for the most recent survey;

(b) Any findings from complaint investigations conducted by State or local surveyors after the most recent licensure survey; and

(c) Any plans of correction in effect with respect to the most recent survey or subsequent complaint investigation; or

(2) A notice describing where in the facility the items listed in §C(1) of this regulation may be found.

D. 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 assisted living program to submit an acceptable plan of correction within 10 calendar days of receipt of the notice of violation or deficiency;

(c) Notifying the assisted living program of sanctions or that failure to correct the violation may result in sanctions; and

(d) Offering the assisted living program the opportunity for informal dispute resolution (IDR).

(2) The plan of correction referred to in §D(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 time frame may result in a sanction.

(3) When a licensee requests an IDR as provided in §E 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, in which case absent the Department's specific 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.

E. Informal Dispute Resolution.

(1) A licensee may request informal dispute resolution (IDR) to question violations or deficiencies within 10 calendar 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.

(4) In the event a licensee requests an IDR of a violation written by a designee of the Department, the Department shall request the designee to participate in the IDR process.