La. Admin. Code tit. 48 § I-8407
Current through Register Vol. 50, No. 11, November 20, 2024
A. All surveys, except the initial licensing survey, shall be unannounced. This survey may be conducted with other agency personnel and/or personnel from other local, state or federal agencies. A survey of all aspects of the facility's operation is required prior to issuing a license.B. Initial Survey. DHH shall determine through an on-site review if the facility is capable of becoming fully operational. The procedures for the on-site review may be obtained from HSS.C. Annual Survey. An on-site survey of the facility is performed or an attestation from the facility is received annually to assure continuous adherence to standards.D. Follow-up Surveys. An on-site visit is performed or documentation is requested for a desk review to ensure that corrective actions have been taken as stated in the plan of corrections and to assure continued compliance between surveys.E. DHH shall determine the type and extent of investigation to be made in response to complaints in accordance with R.S. 40: 2009.13 et seq. 1. The facility may be required to do an internal investigation and submit a report to HSS.2. HSS and other federal, state and local agencies may conduct an on-site focused or complete survey as appropriate.F. Written plans of correction shall be submitted to HSS to describe actions taken by the facility in response to cited violations. The plan must be submitted within 10 days of the date of the receipt of the notice of deficiencies, or the provider may be sanctioned. All components of the corrective action plan must be specific and realistic, including the dates of completion. 1. The correction plan shall include the following components: a. the actions taken to correct any problems caused by a deficient practice directed to a specific patient;b. the actions taken to identify other patients who may also have been affected by a deficient practice, and to assure that corrective action will have a positive impact for all patients;c. the systemic changes made to ensure that the deficient practice will not recur;d. a monitoring plan developed to prevent recurrence; ande. the date(s) when corrective action will be completed.G. Corrections must be completed within 60 days of the survey unless HSS directs that corrective action be completed in less time due to danger or potential danger to patients or staff.La. Admin. Code tit. 48, § I-8407
Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 28:2193 (October 2002), amended LR 30:432 (March 2004).AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153 and R.S. 40:2117.4.