HHSC Survey Process and Enforcement Remedies in Texas: A Compliance Guide for Assisted Living Facilities

The Texas Health and Human Services Commission (HHSC) is responsible for licensing and regulating Assisted Living Facilities (ALFs) and other long-term care providers across Texas. The HHSC survey process is the primary mechanism used to evaluate compliance with the Texas Administrative Code and Health and Safety Code requirements.

When deficiencies are identified, HHSC may impose a range of enforcement remedies, from corrective action plans to administrative penalties or license revocation. Understanding how surveys are conducted and how enforcement actions are triggered is essential for operators seeking to protect licensure and reduce regulatory risk.

This article provides a detailed overview of the HHSC survey process and enforcement remedies in Texas.

Regulatory Authority

Texas Assisted Living Facilities are governed by:

• Texas Administrative Code (TAC), Title 26, Part 1, Chapter 553

• Texas Health and Safety Code, Chapter 247

• HHSC Regulatory Services Division

HHSC has statutory authority to conduct inspections, investigate complaints, issue citations, and impose enforcement remedies.

Types of HHSC Surveys

HHSC conducts several types of inspections:

1. Initial Licensing Survey

Conducted before issuing a new license, this survey verifies:

• Physical plant compliance

• Fire safety approval

• Policy and procedure review

• Staffing readiness

• Administrator qualifications

Licensure is contingent on passing this survey.

2. Routine (Unannounced) Survey

HHSC performs periodic unannounced inspections to assess:

• Resident care delivery

• Staffing sufficiency

• Medication management

• Infection control

• Evacuation drills

• Resident rights compliance

Routine surveys are typically comprehensive.

3. Complaint Investigation

Triggered by:

• Resident or family complaints

• Ombudsman referrals

• Hospital reports

• Staff whistleblower reports

• Law enforcement referrals

Complaint investigations may be focused or expanded depending on findings.

4. Follow-Up Survey

Conducted to verify correction of previously cited deficiencies and confirm compliance.

What Surveyors Evaluate

HHSC surveyors assess compliance through:

• Resident record reviews

• Staff interviews

• Resident interviews

• Direct observation

• Medication pass observation

• Staffing schedule analysis

• Fire drill documentation review

Surveyors evaluate both documentation and real-time operations.

Deficiency Citations

When non-compliance is identified, HHSC issues deficiency citations. Deficiencies are categorized by severity and scope.

Survey findings typically identify:

• Regulatory citation reference

• Description of violation

• Evidence observed

• Required corrective action

Severity is determined by risk to resident health and safety.

Severity Levels

Texas deficiencies are often evaluated based on:

• Potential for harm

• Actual harm

• Immediate jeopardy

Immediate jeopardy is the most serious level and indicates a situation that has caused or is likely to cause serious injury, harm, impairment, or death.

Immediate jeopardy findings can result in rapid enforcement escalation.

Plan of Correction (POC)

After receiving a deficiency report, the facility must submit a Plan of Correction by the deadline specified.

A compliant POC should include:

1. Corrective action taken

2. Measures to prevent recurrence

3. Monitoring system

4. Responsible party

5. Completion timeline

HHSC may reject incomplete or vague plans.

Failure to submit a timely POC can trigger enforcement remedies.

Enforcement Remedies in Texas

HHSC has broad enforcement authority when violations are serious, repeated, or uncorrected.

1. Administrative Penalties (Fines)

HHSC may impose monetary penalties based on:

• Severity of violation

• Frequency of occurrence

• Risk to residents

• Compliance history

Penalties increase for repeat violations.

2. Directed Plan of Correction

HHSC may require:

• Specific corrective actions

• Staff retraining

• Policy revisions

• Monitoring systems

Facilities must comply with directed correction measures.

3. Denial of License Renewal

If compliance history is poor, HHSC may deny renewal of the facility’s license.

4. Suspension or Revocation

In serious cases, HHSC may:

• Suspend the license

• Revoke the license

• Issue emergency suspension

Emergency suspension may occur when resident health or safety is in immediate danger.

5. Suspension of Admissions

HHSC may prohibit a facility from admitting new residents until compliance is restored.

6. Appointment of Temporary Manager

In severe cases, HHSC may appoint a temporary manager to oversee operations.

Immediate Jeopardy Findings

Immediate jeopardy is the highest level of enforcement concern.

Examples include:

• Failure to supervise resulting in serious injury

• Untrained staff administering medications

• Fire safety violations posing immediate danger

• Severe understaffing preventing evacuation

Facilities must remove immediate jeopardy immediately or risk license suspension.

Informal Dispute Resolution (IDR)

Facilities have the right to dispute findings through the Informal Dispute Resolution (IDR) process.

IDR allows facilities to:

• Submit written evidence

• Clarify factual inaccuracies

• Request reconsideration

IDR does not delay enforcement deadlines unless specifically granted.

Strategic documentation is critical when disputing deficiencies.

Repeat Violations and Escalation

HHSC tracks compliance history. Repeat deficiencies may lead to:

• Higher fines

• Escalated monitoring

• Enforcement conference

• Increased inspection frequency

Facilities with repeated violations in high-risk categories face greater enforcement intensity.

Public Disclosure

Survey results and enforcement actions may be publicly accessible through HHSC reporting platforms.

Negative findings can affect:

• Facility reputation

• Referral relationships

• Investor interest

• Insurance underwriting

Reputation management is closely tied to compliance history.

How Surveyors Determine Compliance

HHSC surveyors evaluate:

• Policies vs actual practice

• Staff knowledge

• Resident outcomes

• Documentation consistency

• Incident trends

If documentation conflicts with observation, surveyors rely heavily on observed care delivery.

High-Risk Compliance Areas

Common deficiency areas include:

• Staffing shortages

• Medication errors

• Infection control gaps

• Failure to report abuse or neglect

• Inadequate supervision

• Evacuation non-compliance

• Incomplete resident assessments

Proactive monitoring reduces exposure in these categories.

Compliance Best Practices

1. Conduct Internal Mock Surveys

Quarterly internal audits help identify compliance gaps before HHSC does.

2. Maintain a Survey Readiness Binder

Include:

• License

• Administrator credentials

• Staffing schedules

• Fire drill logs

• Incident reports

• Training documentation

3. Track Incident Trends

Analyze:

• Falls

• Medication errors

• Behavioral incidents

• Hospital transfers

Patterns often trigger complaint investigations.

4. Train Staff on Survey Protocol

Staff should:

• Answer accurately

• Provide requested documents promptly

• Avoid speculation

Prepared staff reduce survey risk.

5. Monitor Staffing Continuously

Inadequate staffing is one of the most common enforcement triggers in Texas ALFs.

Investor and Operational Impact

HHSC enforcement actions can impact:

• Property valuation

• Business acquisitions

• Financing eligibility

• Market competitiveness

Facilities with strong compliance histories are more attractive to investors and lenders.

Conclusion

The HHSC survey process in Texas is structured, documentation-driven, and focused on resident safety. Enforcement remedies range from corrective action plans to license suspension depending on severity and compliance history.

Understanding deficiency classification, timely submission of plans of correction, and proactive compliance systems are essential to protecting licensure.

Facilities that treat survey readiness as an ongoing operational priority rather than a reactive task are significantly more stable and resilient in the regulatory environment.

Authoritative URL References

Texas Health and Human Services Commission – Assisted Living Regulation
https://www.hhs.texas.gov/providers/long-term-care-providers/assisted-living-facilities-alf

Texas Administrative Code – Chapter 553 Assisted Living Facilities
https://texreg.sos.state.tx.us

Texas Health and Safety Code Chapter 247
https://statutes.capitol.texas.gov

HHSC Regulatory Services Division
https://www.hhs.texas.gov