175 Neb. Admin. Code, ch. 12, § 005 - INSPECTIONS

To determine compliance with operational, care, treatment, and physical plant standards, the Department inspects skilled nursing facilities, nursing facilities, and intermediate care facilities prior to and following licensure. The Department determines compliance through on-site inspections, review of schematic and construction plans, and reports of qualified inspectors.

005.01 Initial Inspection

The Department will conduct an announced initial on-site inspection to determine compliance with 175 NAC 12-006 and 12-007. The inspection will be conducted within 30 working days, or later if requested by the applicant, of receipt of a completed application for an initial license. The Department will provide a copy of the inspection report to the facility within ten working days after completion of an inspection.

005.02 Results of Initial Inspection

12-005.02A When the Department finds that the applicant fully complies with the requirements of 175 NAC 12-006 and 12-007, the Department will issue a license.

12-005.02B When the Department finds that the applicant has complied substantially but has failed to comply fully with the requirements of 175 NAC 12-006 and 12-007 and the failure(s) would not pose an imminent danger of death or physical harm to residents of the facility, the Department may issue a provisional license. The provisional license:

1. Is valid for up to one year; and

2. Is not renewable.

12-005.02C When the Department finds the applicant has one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse relationship to the health, safety, or security of the residents of the facility, the Department may send a letter to the facility requesting a statement of compliance. The letter will include:

1. A description of each violation;

2. A request that the facility submit a statement of compliance within ten working days; and

3. A notice that the Department may take further steps if the statement of compliance is not submitted.

12-005.02D The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

1. If the facility submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will issue either a regular license or a provisional license; or

2. If the facility fails to submit and implement a statement of compliance that indicates a good faith effort to correct the violations, the Department may deny the license.

12-005.02E When the Department finds the applicant fails to meet the requirements of 175 NAC 12-006 and 12-007 and the failure(s) would create an imminent danger of death or serious physical harm, the Department will deny the license.

005.03 Physical Plant Inspections

The Department will conduct inspections for conformity with construction plans and compliance with 175 NAC 12-007 for new construction and new facilities in accordance with the following:

12-005.03A On-site progress inspections of the physical plant by qualified inspectors for conformity to construction documents and compliance with code requirements may occur at any time after construction has begun and prior to the concealment of essential components.

12-005.03B The Department will conduct an on-site final inspection of the physical plant prior to use or occupancy. In lieu of an on-site final inspection by the Department, the Department may accept a certification from a licensed architect or engineer that the physical plant meets the requirements of the Health Care Facility Licensure Act and 175 NAC 12, and that the facility is complete and ready for occupancy in accordance with Department-approved plans. The architect or engineer may construct a certification form or obtain a certification form from the Department.

12-005.03B1 The certification must state:

1. Name of the architect or engineer;

2. Name of the professional entity with which he or she is affiliated, if any;

3. Address and telephone number;

4. Type of license held, the state in which it is held, and the license number;

5. Name and location of the facility;

6. Name(s) of the owner(s) of the facility;

7. New construction had the building structure and plumbing rough-in inspected by a qualified inspector prior to the time these would be concealed and preclude observation;

8. All new construction is completed in accordance with approved construction plans; and

9. The facility is furnished, cleaned, and equipped for the care and treatment to be performed in compliance with 175 NAC 12-007, and approved for use and occupancy.

12-005.03B2 The certification must have attached to it:

1. Copies of documents from other authorities having jurisdiction verifying the facility meets the codes specified in 175 NAC 12-007.03A, and is approved for use and occupancy;

2. Copies of certifications and documentation from equipment and building system installers verifying that all equipment and systems installed are operating and approved for use and occupancy; and

3. Schematic floor plans documenting actual room numbers and titles, bed locations and capacity, and life safety information.

005.04 Compliance Inspections

The Department may, following the initial licensure of a facility, conduct an unannounced onsite inspection at any time it deems necessary to determine compliance with 175 NAC 12-006 and 12-007. The inspection may occur based on random selection or focused selection.

12-005.04A Random Selection: Each year the Department may inspect up to 25% of the skilled nursing facilities, nursing facilities, and intermediate care facilities based on a random selection of licensed skilled nursing facilities, nursing facilities, and intermediate care facilities.

12-005.04B Focused Selection: The Department may inspect a skilled nursing facility, nursing facility, or intermediate care facility when the Department is informed of one or more of the following:

1. An occurrence resulting in resident death or serious physical harm;

2. An occurrence resulting in imminent danger to or the possibility of death or serious physical harm to residents;

3. An accident or natural disaster resulting in damage to the physical plant and having a direct or immediate adverse effect on the health, safety, and security of residents;

4. The passage of five years without an inspection;

5. A complaint alleging violation of the Health Care Facility Licensure Act or 175 NAC 12;

6. Complaints that, because of their number, frequency, or type, raise concerns about the maintenance, operation, or management of the facility;

7. Financial instability of the licensee or the licensee's parent company;

8. Outbreaks or recurrent incidents of physical health problems such as dehydration, pressure sores, or other illnesses;

9. Change of services, management or ownership;

10. Change in status of accreditation or certification on which licensure is based, as provided in 175 NAC 12-004.09; or

11. Any other event that raises concerns about the maintenance, operation, or management of the facility.

005.05 Results of Compliance Inspections

12-005.05A When the inspection reveals violations that create imminent danger of death or serious physical harm or have a direct or immediate adverse effect on the health, safety, or security of the facility's residents, the Department will review the inspection findings within 20 working days after the inspection. If the evidence from the inspection supports the findings, the Department will impose discipline in accordance with 175 NAC 12-008.03.

12-005.05B When the inspection reveals one or more violations that create no imminent danger of death or serious physical harm and no direct or immediate adverse effect on the health, safety, or security of the facility's residents, the Department may request a statement of compliance from the facility. The statement of compliance must indicate any steps that have been or will be taken to correct each violation and the estimated time to correct each violation. Based on the statement of compliance, the Department will take one of the following actions:

1. If the facility submits and implements a statement of compliance that indicates a good faith effort to correct the violations, the Department will not take any disciplinary action against the license; or

2. If the facility fails to submit and implement a statement of compliance, the Department will initiate disciplinary action against the license in accordance with 175 NAC 12-008.

005.06 Re-Inspections

12-005.06A The Department may conduct re-inspections to determine if a facility fully complies with the requirements of 175 NAC 12-006 and 12-007. Re-inspection occurs:

1. After the Department has issued a provisional license;

2. Before a provisional license is converted to a regular license;

3. Before a disciplinary action is modified or terminated; or

4. After the Department receives a statement of compliance for cited violations.

12-005.06B Following a re-inspection, the Department may:

1. Convert a provisional license to a regular license;

2. Affirm that the provisional license is to remain effective;

3. Modify a disciplinary action in accordance with 175 NAC 12-008.02; or

4. Grant full reinstatement of the license.

Notes

175 Neb. Admin. Code, ch. 12, § 005