Proposed Rules Title 26

TITLE 26. HEALTH AND HUMAN SERVICES

PART 1. HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 506. SPECIAL CARE FACILITIES

SUBCHAPTER C. OPERATIONAL REQUIREMENTS

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes new §506.40, concerning Advance Directives Reporting Requirements.

BACKGROUND AND PURPOSE

The purpose of the proposal is to implement House Bill (H.B.) 3162, 88th Legislature, Regular Session, 2023. H.B. 3162 amended Texas Health and Safety Code (HSC) Chapter 166 Subchapters B and E and HSC Chapter 313.

HSC §166.046, as amended by H.B. 3162, in part requires a facility's ethics or medical committee to review a physician's refusal to honor an advance directive or health care or treatment decision made by or on behalf of a patient determined to be incompetent or otherwise mentally or physically incapable of communication. Amended HSC §166.046 also requires the facility to provide a written notice to the person responsible for the patient's health care decisions that the facility's ethics or medical committee will meet at least seven days later to review the physician's refusal to honor the patient's advanced directive or health care treatment decision.

HSC §166.054, as added by H.B. 3162, requires health care facilities to report certain information to HHSC within 180 days after the health care facility provides the written notice required under HSC §166.046. New HSC §166.054 also requires HHSC to adopt rules for reporting, protecting, and aggregating this information.

SECTION-BY-SECTION SUMMARY

Proposed new §506.40(a) ensures consistency with amended HSC §166.054 by requiring a facility to complete and submit the Ethics or Medical Committee Reporting Form to HHSC after the facility provides the written notice required under HSC §166.046(b)(1) and describes the information collected in the form.

New subsection (b) describes the process of publishing the aggregate report.

New subsection (c) provides how the information in the forms may not be used.

FISCAL NOTE

Trey Wood, HHSC Chief Financial Officer, has determined that for each year of the first five years that the rule will be in effect, enforcing or administering the rule does not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rule will be in effect:

(1) the proposed rule will not create or eliminate a government program;

(2) implementation of the proposed rule will not affect the number of HHSC employee positions;

(3) implementation of the proposed rule will result in no assumed change in future legislative appropriations;

(4) the proposed rule will not affect fees paid to HHSC;

(5) the proposed rule will create a new regulation;

(6) the proposed rule will not expand existing regulations;

(7) the proposed rule will not change the number of individuals subject to the rule; and

(8) the proposed rule will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Trey Wood has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities because the proposed rule does not impose a cost or require small businesses, micro-businesses, or rural communities to alter their current business practices.

LOCAL EMPLOYMENT IMPACT

The proposed rule will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to this rule because the rule does not impose a cost on regulated persons and is necessary to implement legislation that does not specifically state that §2001.0045 applies to the rule.

PUBLIC BENEFIT AND COSTS

Stephen Pahl, Deputy Executive Commissioner for Regulatory Services, has determined that for each year of the first five years the rule is in effect, the public will benefit from increased consistency between the special care facility rules and new statutory requirements for advanced directives.

Trey Wood has also determined that for the first five years the rule is in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rule because the rule does not require persons subject to the rules to alter their current business practices; these entities are required to comply with the law as added by H.B. 3162 and the proposed new section only ensures consistency with current statutory requirements and codifies the name of the reporting form in rule.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to the owner's property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal may be submitted to Rules Coordination Office, P.O. Box 13247, Mail Code 4102, Austin, Texas 78711-3247, or street address 701 W. 51st Street, Austin, Texas 78751; or emailed to HCR_PRU@hhs.texas.gov.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 24R003" in the subject line.

STATUTORY AUTHORITY

The new section is authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies; HSC §248.006, which requires HHSC to adopt rules establishing minimum standards for special care facilities; and HSC §166.054, which requires HHSC to adopt rules to establish a standard form for the requirements for reporting meetings of an ethics or medical committee meeting to review a physician's refusal to honor an advance directive of or health care or treatment decision made by or on behalf of a patient who is determined to be incompetent or is otherwise mentally or physically incapable of communication and to protect and aggregate any information HHSC receives under this section.

The new section implements Texas Government Code §531.0055 and HSC §166.046, §166.0465, §166.052, and §166.054.

§506.40.Advance Directives Reporting Requirements.

(a) Pursuant to Texas Health and Safety Code (HSC) §166.054, a facility shall complete and submit to the Texas Health and Human Services Commission (HHSC) the Ethics or Medical Committee Reporting Form, which is located on the Texas HHSC website, no later than the 180th day after the facility delivers the written notice required under HSC §166.046(b)(1). The Ethics or Medical Committee Reporting Form collects the following information:

(1) the number of days that elapsed from the patient's admission to the facility to the date notice was provided under HSC §166.046(b)(1);

(2) whether the ethics or medical committee met to review the case under HSC §166.046 and, if the committee did meet, the number of days that elapsed from the date notice was provided under HSC §166.046(b)(1) to the date the meeting was held;

(3) whether the patient was:

(A) transferred to a physician within the same facility who was willing to comply with the patient's advance directive or a health care or treatment decision made by or on behalf of the patient;

(B) transferred to a different health care facility; or

(4) whether the patient died while receiving life-sustaining treatment at the facility;

(5) whether life-sustaining treatment was withheld or withdrawn from the patient at the facility after expiration of the time period described by HSC §166.046(e) and, if so, the disposition of the patient after the withholding or withdrawal of life-sustaining treatment at the facility, as selected from the following categories:

(A) the patient died at the facility;

(B) the patient is currently a patient at the facility;

(D) the patient was discharged from the facility to a private residence or other setting that is not a health care facility;

(6) the age group of the patient selected from the following categories:

(A) 17 years of age or younger;

(B) 18 years of age or older and younger than 66 years of age; or

(7) the health insurance coverage status of the patient selected from the following categories:

(A) private health insurance coverage;

(B) public health plan coverage; or

(8) the patient's sex;

(9) the patient's race;

(10) whether the facility was notified of and able to reasonably verify any public disclosure of the contact information for the facility's personnel, physicians or health care professionals who provide care at the facility, or members of the ethics or medical committee in connection with the patient's stay at the facility; and

(11) whether the facility was notified of and able to reasonably verify any public disclosure by facility personnel of the contact information for the patient's immediate family members or the person responsible for the patient's health care decisions in connection with the patient's stay at the facility.

(b) In accordance with HSC §166.054(c)-(e), HHSC publishes on its website an aggregate report of information submitted under subsection (a) of this section in the preceding year by April 1 of each year.

(1) is not admissible in a civil or criminal proceeding in which a physician, health care professional acting under the direction of a physician, or health care facility is a defendant;

(2) may not be used in relation to any disciplinary action by a licensing or regulatory agency with oversight over a physician, health care professional acting under the direction of a physician, or health care facility; and

(3) is not public information or subject to disclosure under Texas Government Code Chapter 552, except as permitted by Texas Government Code §552.008.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402385

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 834-4591

CHAPTER 550. LICENSING STANDARDS FOR PRESCRIBED PEDIATRIC EXTENDED CARE CENTERS

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §§550.1, 550.5, 550.101 - 550.106, 550.108 - 550.115, 550.118 - 550.123, 550.202, 550.203, 550.205 - 550.207, 550.210, 550.211, 550.301, 550.303 - 550.306, 550.308 - 550.311, 550.402 - 550.406, 550.409 - 550.411, 550.413, 550.415, 550.417, 550.418, 550.504, 550.506 - 550.508, 550.510, 550.511, 550.601 - 550.608, 550.701, 550.703, 550.705, 550.707, 550.802, 550.803, 550.901 - 550.906, 550.1001 - 550.1003, 550.1101, 550.1102, 550.1202 - 550.1204, 550.1206, 550.1207, 550.1211, 550.1215, 550.1217 - 550.1220, 550.1222, 550.1224, 550.1301 - 550.1305, and 550.1401 - 550.1408.

BACKGROUND AND PURPOSE

The purpose of this proposal is to implement provisions of House Bill (H.B.) 1009 and H.B. 3550 from the 88th Legislature, Regular Session, 2023, that apply to Prescribed Pediatric Extended Care Centers (PPECC). H.B. 1009 requires a facility to suspend an employee who has been found by HHSC to have engaged in reportable conduct for purposes of inclusion on the Employee Misconduct Registry during any appeals. H.B. 3550 establishes minimum standards for transportation services whereby a center coordinates the schedule of transportation services with a minor's parent, guardian, or other legally authorized representative; determines what type of provider needs to be present during transportation; and permits a minor's parent, guardian, or other legally authorized representative to decline a center's transportation services entirely or only on a specific date. The proposed rules also set forth that a center may not require a plan of care or physician's order to document a minor's need for transportation services to access PPECC services or consider transportation services as nursing services in a minor's plan of care. In addition, the proposed rules update terminology and references and reflect current processes.

SECTION-BY-SECTION SUMMARY

Proposed amendments throughout the chapter update citations and references and restructure sentences to use active voice. Proposed amendments throughout the chapter replace "facility" with "center" for consistency.

The proposed amendment to §550.1, Purpose, replaces references to DADS and updates wording for better understanding.

The proposed amendment to §550.5, Definitions, corrects capitalization errors, deletes definitions made obsolete by organizational changes, corrects numbering changed by the deletion of obsolete definitions, updates the definition for "center," and adds a definition for "online portal." It also defines "immediate threat to the health or safety of a minor."

The proposed amendment to §550.101, Criteria and Eligibility for a License, updates outdated agency references.

The proposed amendment to §550.102, General Application Requirements, updates outdated references to DADS and Texas Administrative Code (TAC), Title 40 §15, and updates processes.

The proposed amendment to §550.103, Building Approval, updates outdated references to DADS and updates processes.

The proposed amendment to §550.104, Applicant Disclosure Requirements, updates outdated references to DADS and updates processes.

The proposed amendment to §550.105, Initial License Application Procedures and Issuance, updates outdated references to 40 TAC §15, updates processes, and deletes obsolete portions of the processes.

The proposed amendment to §550.106, Renewal License Application Procedures and Issuance, updates outdated references to 40 TAC §15, updates processes, and deletes obsolete portions of the processes.

The proposed amendment to §550.108, Change of Ownership License Application Procedures and Issuance and Notice of Changes, adds language to clarify processes.

The proposed amendment to §550.109, Increase in Capacity, updates outdated references to DADS and 40 TAC §15 and updates processes.

The proposed amendment to §550.110, Decrease in Capacity, updates processes.

The proposed amendment to §550.111, Relocation, updates outdated references to DADS and 40 TAC §15, updates processes, and deletes obsolete portions of the processes.

The proposed amendment to §550.112, Licensing Fees, updates outdated references to 40 TAC §15.

The proposed amendment to §550.113, Plan Review Fees, updates outdated references to DADS.

The proposed amendment to §550.114, Time Periods for Processing All Types of License Applications, updates outdated references to DADS and 40 TAC §15, updates processes, and deletes obsolete portions of the processes.

The proposed amendment to §550.115, Criteria for Denial of a License, updates outdated references to DADS and 40 TAC §15, updates processes, and deletes obsolete portions of the processes.

The proposed amendment to §550.118, Reporting Changes in Application Information, updates outdated references to DADS and 40 TAC §15 and updates processes.

The proposed amendment to §550.119, Notification Procedures for a Change in Administration and Management, updates outdated references to DADS and updates processes.

The proposed amendment to §550.120, Notification Procedures for a Change of Contact Information, updates processes.

The proposed amendment to §550.121, Notification Procedures for a Change in Operating Hours, updates outdated references to DADS and updates processes.

The proposed amendment to §550.122, Notification Procedures for a Name Change, updates outdated references to DADS and 40 TAC §15 and updates processes.

The proposed amendment to §550.123, Request and Issuance of Temporary License, updates outdated references to DADS and 40 TAC §15 and updates processes.

The proposed amendment to §550.202, Suspension of Operations, updates outdated references to DADS and 40 TAC §15 and updates processes.

The proposed amendment to §550.203, Financial Solvency and Business Records, updates outdated references to DADS.

The proposed amendment to §550.205, Safety Provisions, makes clarifying edits and updates outdated references to DADS.

The proposed amendment to §550.206, Person-Centered Direction and Guidance, updates an outdated reference to DADS.

The proposed amendment to §550.207, Protective Devices and Restraints, makes clarifying edits and updates outdated references to 40 TAC §15.

The proposed amendment to §550.210, Sanitation, Housekeeping, and Linens, makes clarifying edits.

The proposed amendment to §550.211, Infection Prevention and Control Program and Vaccinations Requirements, clarifies references.

The proposed amendment to §550.301, License Holder's Responsibilities, updates outdated references to DADS and 40 TAC §15 and §99 and clarifies processes.

The proposed amendment to §550.303, Administrator and Alternate Administrator Qualifications and Conditions, updates outdated references to 40 TAC §15 and §99 and clarifies wording.

The proposed amendment to §550.304, Administrator Responsibilities, updates outdated references to 40 TAC §15 and updates processes.

The proposed amendment to §550.305, Initial Training in Administration, updates outdated references to DADS and 40 TAC §15 and makes minor edits to improve readability.

The proposed amendment to §550.306, Continuing Training in Administration, updates outdated references to DADS and 40 TAC §15.

The proposed amendment to §550.308, Medical Director Responsibilities, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.309, Nursing Director and Alternate Nursing Director Qualifications and Conditions, makes edits for clarity and consistency.

The proposed amendment to §550.310, Nursing Director Responsibilities and Supervision Responsibilities, updates outdated references to 40 TAC §15.

The proposed amendment to §550.311, Prohibition of Solicitation, updates an outdated reference to DADS.

The proposed amendment to §550.402, Registered Nurse Qualifications, corrects a medical term and updates outdated references to 40 TAC §15.

The proposed amendment to §550.403, Registered Nurse Responsibilities, updates wording for active voice and renumbers accordingly.

The proposed amendment to §550.404, Licensed Vocational Nurse Qualifications, updates outdated references to 40 TAC §15 and corrects a spelling mistake.

The proposed amendment to §550.405, Licensed Vocational Nurse Responsibilities, updates wording for active voice and renumbers accordingly.

The proposed amendment to §550.406, Student Nurses, updates outdated references to 40 TAC §15.

The proposed amendment to §550.409, Direct Care Staff Qualifications, updates outdated references to 40 TAC §15 and corrects a medical term.

The proposed amendment to §550.410, Nursing Services Staffing Ratio, updates outdated references to 40 TAC §15, renames the figure, and deletes an inaccurate sentence.

The proposed amendment to §550.411, Rehabilitative and Ancillary Professional Staff and Qualifications, updates wording for active voice.

The proposed amendment to §550.413, Contractors, updates outdated references to 40 TAC §15 and DADS.

The proposed amendment to §550.415, Staffing Policies for Staff Orientation, Development, and Training, updates outdated references to 40 TAC §15 and corrects grammatical errors.

The proposed amendment to §550.417, Personnel Records, updates outdated references to 40 TAC §15.

The proposed amendment to §550.418, Criminal History Checks, Nurse Aide Registry (NAR), and Employee Misconduct Registry (EMR) Requirements, updates the section title and outdated references to DADS, replaces acronyms with proper names, updates a process, and implements H.B. 1009 by requiring a facility to suspend an employee HHSC has found to have engaged in reportable conduct and placed on the EMR and to maintain that suspension during any appeals process.

The proposed amendment to §550.504, Psychosocial Treatment and Services, updates outdated references to 40 TAC §15.

The proposed amendment to §550.506, Rehabilitative Services, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.507, Functional Developmental Services, corrects a reference.

The proposed amendment to §550.508, Educational Developmental Services, moves an acronym definition and updates an outdated United States Code reference.

The proposed amendment to §550.510, Nutritional Counseling, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.511, Dietary Services, updates outdated references to 40 TAC §15 and updates the agency name.

The proposed amendment to §550.601, Admission Criteria, adds detail to who can consent admission to a center and updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.602, Pre-admission Conference, updates an outdated reference to 40 TAC §15 and clarifies wording.

The proposed amendment to §550.603, Agreement and Disclosure, updates outdated references to 40 TAC §15, corrects grammatical errors, updates the agency name, and adds wording for clarity.

The proposed amendment to §550.604, Admission Procedures, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.605, Initial and Updated Comprehensive Assessment, adds language for clarity and corrects grammatical errors.

The proposed amendment to §550.606, Interdisciplinary Team, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.607, Initial and Updated Plan of Care, corrects grammatical errors.

The proposed amendment to §550.608, Discharge or Transfer Notification, updates an outdated reference to 40 TAC §15 and replaces a word for clarity.

The proposed amendment to §550.701, Physician Orders, corrects a grammatical error.

The proposed amendment to §550.703, Pharmacist Services, updates outdated references to 40 TAC §15.

The proposed amendment to §550.705, Administration of Medication, adds a word for clarity.

The proposed amendment to §550.707, Disposal of Special or Medical Waste, updates the agency name and a reference.

The proposed amendment to §550.802, Coordination of Services, updates wording for active voice.

The proposed amendment to §550.803, Census, updates outdated references to DADS.

The proposed amendment to §550.901, Rights and Responsibilities, updates outdated references to 40 TAC §15 and DADS, updates processes, and corrects a grammatical error.

The proposed amendment to §550.902, Advance Directives, updates an outdated reference to DADS and replaces a word for clarity.

The proposed amendment to §550.903, Abuse, Neglect, or Exploitation Reportable to DADS, updates the section title and outdated references to DADS, corrects a grammatical error, and updates processes.

The proposed amendment to §550.904, Investigations of a Complaint and Grievance, updates an outdated reference to DADS.

The proposed amendment to §550.905, Reporting of a Minor's Death, updates outdated references to DADS.

The proposed amendment to §550.906, Examination of Inspection Results, updates an outdated reference to DADS.

The proposed amendment to §550.1001, Medical Records, updates outdated references to 40 TAC §15, corrects grammatical errors, and rewords language for clarity.

The proposed amendment to §550.1002, Quality Assessment and Performance Improvement, updates an outdated reference to DADS and replaces an acronym with a proper name.

The proposed amendment to §550.1003, Dissolution, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1101, Transportation Services, implements H.B. 3550 by clarifying which staff accompany minors during transportation and how that is determined.

The proposed amendment to §550.1102, Transportation Safety Provisions, implements H.B. 3550 by clarifying which staff accompany minors during transportation and how that is determined and replaces a proper name with an acronym.

The proposed amendment to §550.1202, Plan Reviews, updates outdated references to DADS and 40 TAC §15, rewords language for clarity, and corrects a grammatical error.

The proposed amendment to §550.1203, Design Criteria, updates outdated references to DADS.

The proposed amendment to §550.1204, Fire Safety, updates outdated references to DADS and replaces an acronym with a proper name.

The proposed amendment to §550.1206, Exterior Spaces, updates an outdated reference to DADS.

The proposed amendment to §550.1207, Interior Spaces, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1211, Linen Storage, updates outdated references to 40 TAC §15.

The proposed amendment to §550.1215, Garbage, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1217, Laundry, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1218, Housekeeping, updates outdated references to 40 TAC §15 and corrects a typo.

The proposed amendment to §550.1219, Maintenance, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1220, Heating, Ventilation, Air Conditioning (HVAC), updates the section title, replaces an acronym with a proper name, and adds a word for clarity.

The proposed amendment to §550.1222, Sewage, updates an outdated reference to 40 TAC §15.

The proposed amendment to §550.1224, Waivers, updates outdated references to DADS.

The proposed amendment to §550.1301, Inspections and Visits, updates outdated references to DADS.

The proposed amendment to §550.1302, Investigation of Complaints and Self-Reported Incidents, updates outdated references to DADS.

The proposed amendment to §550.1303, Cooperation with an Inspection and Visit, updates outdated references to DADS and adds subsections to clarify requirements and limitations for a center recording HHSC staff.

The proposed amendment to §550.1304, Staff Requirements for an Inspection, updates outdated references to DADS and to 40 TAC §15.

The proposed amendment to §550.1305, General Provisions, updates outdated references to DADS, adds an acronym, corrects a grammatical error, and adds wording for clarity.

The proposed amendment to §550.1401, Denial of License Application, updates outdated references to DADS and 40 TAC §15.

The proposed amendment to §550.1402, License Suspension, updates outdated references to DADS, 40 TAC §15, and 26 TAC §99.

The proposed amendment to §550.1403, Emergency License Suspension, updates outdated references to DADS and corrects grammatical errors.

The proposed amendment to §550.1404, License Revocation, updates outdated references to DADS, 40 TAC §15, and 26 TAC §99, and replaces a proper name with an acronym.

The proposed amendment to §550.1405, Probation, updates outdated references to DADS.

The proposed amendment to §550.1406, Injunctive Relief or Civil Penalties, updates outdated references to DADS.

The proposed amendment to §550.1407, Opportunity to Show Compliance, updates outdated references to DADS and corrects a grammar error.

The proposed amendment to §550.1408, Administrative Penalties, corrects the figure name to Figure 26 TAC §550.1408(m) to show that it has moved from 40 TAC §15.

FISCAL NOTE

Trey Wood, Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules does not have foreseeable implications relating to costs or revenues of state or local government.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of HHSC employee positions;

(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) the proposed rules will not affect fees paid to HHSC;

(5) the proposed rules will create new regulations;

(6) the proposed rules will expand existing regulations;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) the proposed rules will not affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Trey Wood has also determined that there will be an adverse economic effect on small businesses or micro-businesses, or rural communities.

A PPECC may incur a cost due to the implementation of H.B. 1009 if an agency staff person is suspended while he or she goes through due process or appeals process for being added to the EMR. This might not impact all PPECCs but could affect those that may need to hire additional staff on a temporary basis while the staff person is on suspension.

HHSC lacks sufficient information to determine the number of small businesses, micro-businesses, or rural communities subject to the rule.

HHSC determined that alternative methods to achieve the purpose of the proposed rule for small businesses, micro-businesses, or rural communities would not be consistent with ensuring the health and safety of PPECC clients.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules are necessary to protect the health, safety, and welfare of the residents of Texas, including clients of PPECCs, and to implement legislation that does not specifically state that §2001.0045 applies to the rule.

PUBLIC BENEFIT AND COSTS

Stephen Pahl, Deputy Executive Commissioner for Regulatory Services, has determined that for each year of the first five years the rules are in effect, the public will benefit from increased clarity in the rules and guidance in the requirements for PPECCs.

Trey Wood has also determined that there could be a cost for providers required to comply with this proposed rule.

HHSC lacks sufficient information to determine the number of small businesses, micro-businesses, or rural communities subject to the rule.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Questions about the content of this proposal may be directed to Cecilia Cavuto in HHSC Long-term Care Regulation at HHSCLTCRRules@hhs.texas.gov.

Written comments on the proposal may be submitted to Cecilia Cavuto, Program Specialist, Texas Health and Human Services Commission, Mail Code E-370, 701 W. 51st Street, Austin, Texas 78751, or by email to HHSCLTCRRules@hhs.texas.gov.

SUBCHAPTER A. PURPOSE, SCOPE, LIMITATIONS, COMPLIANCE, AND DEFINITIONS

26 TAC §550.1, §550.5

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §531.0055, which provides that the Executive Commissioner of HHSC shall adopt rules for the operation and provision of services by the health and human services agencies, and Texas Human Resources Code §103.004 and §103.005, which respectively provide that the Executive Commissioner of HHSC shall adopt rules for implementing Chapter 103 and adopt rules for licensing and setting standards for facilities licensed under Chapter 103.

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1.Purpose.

(a) The purpose of this chapter is to implement THSC Chapter 248A, which directs the executive commissioner [~~of the Texas Health and Human Services Commission~~] to adopt minimum standards that a person must meet to be licensed as a center.

(b) Except as provided by THSC §248A.002, a person may not own or operate a center unless the person holds a license issued by HHSC [~~DADS~~] under THSC Chapter 248A and this chapter.

(c) An applicant may not provide services under a license for which an application has been submitted [~~filed~~] until HHSC [~~DADS~~] issues the license.

§550.5.Definitions.

The following words and terms, when used in this chapter, have the following meanings unless the context clearly indicates otherwise.

(1) Active Play--Any physical activity from which a minor derives amusement, entertainment, enjoyment, or satisfaction by taking a participatory rather than a passive role. Active play includes various forms of activities, from the exploration of objects and toys to the structured play of formal games, sports, and hobbies.

(2) Actual census--The number of minors at a center at any given time.

(3) Administration of medication--The direct application of a medication to the body of a minor by any route. This includes removing an individual or unit dose from a previously dispensed, correctly labeled container, verifying it with the medication order, giving the correct medication and the correct dose to the correct minor at the correct time by the correct route, and accurately recording the time and dose given.

(4) Administrator--The person who is responsible for implementing and supervising the administrative polices and operations of a center and for administratively supervising the provision of services to minors and their parents on a day-to-day basis.

(5) Adult minor--A minor who is 18 years of age or older or is emancipated[,] and has not been adjudged incompetent.

(6) Affiliate--With respect to an applicant or license holder that is:

(A) a corporation--means an officer, director, or stockholder with direct ownership or disclosable interest of at least five percent, a subsidiary, or a parent company;

(B) a limited liability company--means an officer, member, or parent company;

(i) the individual's spouse;

(ii) each partnership and each partner thereof of which an individual or any affiliate of an individual is a partner; and

(iii) each corporation in which an individual is an officer, director, or stockholder with a direct ownership of at least five percent;

(D) a partnership--means a partner or a parent company of the partnership; and

(E) a group of co-owners under any other business arrangement means an officer, director, or the equivalent under the specific business arrangement or a parent company.

(7) Applicant--A person who applies for a license to operate a center under THSC Chapter 248A and this chapter. The applicant is the person in whose name HHSC issues the license.

(8) Audiologist--A person who has a valid license under Texas Occupations Code, Chapter 401, as an audiologist.

(9) Basic services--Include:

(A) the development, implementation, and monitoring of a comprehensive protocol of care that:

(i) is provided to a medically dependent or technologically dependent minor;

(ii) is developed in conjunction with the minor's parent; and

(iii) specifies the medical, nursing, psychosocial, therapeutic, and developmental services required by the minor; and

(B) the caregiver training needs of a medically dependent or technologically dependent minor's parent.

(10) Behavioral emergency--A situation that occurs after which preventative or de-escalating techniques are attempted and determined to be ineffective and it is immediately necessary to restrain a minor to prevent immediate probable death or substantial bodily harm to the minor or to others because the minor is attempting serious bodily harm or immediate physical harm to the minor or to others.

(11) Business day--Any day except a national or state holiday listed in Texas Government Code §662.003(a) or (b). The term includes Saturday or Sunday if the center is open on that day.

(12) Center--A Prescribed Pediatric Extended Care Center [~~prescribed pediatric extended care center~~]. A facility operated for profit or on a nonprofit basis that provides nonresidential basic services to four or more medically dependent or technologically dependent minors who require the services of the center [~~facility~~] and who are not related by blood, marriage, or adoption to the owner or operator of the center [~~facility~~].

(13) Change of ownership--An event that results in a change to the federal taxpayer identification number of the license holder of a facility. The substitution of a personal representative for a deceased license holder is not a change of ownership.

(14) Chemical restraint--The use of any chemical, including pharmaceuticals, through topical application, oral administration, injection, or other means, to restrict the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior and which is not a standard treatment for a minor's medical or psychosocial condition.

(15) Chief financial officer--An individual who is responsible for supervising and managing all financial activities for a center.

(16) Clinical note--A notation of a contact with a minor or a minor's family member that is written and dated by any staff providing services on behalf of a center and that describes signs and symptoms of the minor, and treatments and medications administered to the minor, including the minor's reaction or response, and any changes in physical, emotional, psychosocial, or spiritual condition of the minor during a given period of time.

~~[(17) Commission--The Texas Health and Human Services Commission.]~~

~~[(18) Commissioner--The term referred to the commissioner of DADS; it now refers to the executive commissioner of HHSC.]~~

(17) [~~(19)~~] Community disaster resources--A local, statewide, or nationwide emergency system that provides information and resources during a disaster, including weather information, transportation, evacuation and shelter information, disaster assistance and recovery efforts, evacuee and disaster victim resources, and resources for locating evacuated friends and relatives.

(18) [~~(20)~~] Complaint--An allegation against a center or involving services provided at a center that involves a violation of this chapter or THSC Chapter 248A.

(19) [~~(21)~~] Continuous face-to-face observation--Maintaining an in-person line of sight of a minor that is uninterrupted and free from distraction.

(20) [~~(22)~~] Contractor--An individual providing services ordered by a prescribing physician on behalf of a center that the center would otherwise provide by its employees.

(21) [~~(23)~~] Controlling person--A person who has the ability, acting alone or in concert with others, to directly or indirectly influence, direct, or cause the direction of the management of, expenditure of money for or policies of a center or other person.

(A) A controlling person includes:

(i) a management company, landlord, or other business entity that operates or contracts with another person for the operation of a center;

(ii) any person who is a controlling person of a management company or other business entity that operates a center or that contracts with another person for the operation of a center; and

(iii) any other person who, because of a personal, familial, or other relationship with the owner, manager, landlord, tenant, or provider of a center, is in a position of actual control of or authority with respect to the center, regardless of whether the person is formally named as an owner, manager, director, officer, provider, consultant, contractor, or employee of the center.

(B) Notwithstanding any other provision of this paragraph, a controlling person of a center or of a management company or other business entity described by subparagraph (A)(i) of this paragraph that is a publicly traded corporation or is controlled by a publicly traded corporation means an officer or director of the corporation. The term does not include a shareholder or lender of the publicly traded corporation.

(C) A controlling person described by subparagraph (A)(iii) of this paragraph does not include a person, including an employee, lender, secured creditor, or landlord, who does not exercise any formal or actual influence or control over the operation of the center.

(22) [~~(24)~~] Conviction--An adjudication of guilt based on a finding of guilt, a plea of guilty, or a plea of nolo contendere.

~~[(25) DADS--The term referred to the Department of Aging and Disability Services; it now refers to HHSC.]~~

(23) [~~(26)~~] Daily census--The number of minors served at a center during a center's hours of operation for a 24-hour period, starting at midnight.

(24) [~~(27)~~] Day--A calendar day, unless otherwise specified in the text. A calendar day includes Saturday, Sunday, and a holiday.

(25) [~~(28)~~] Dietitian--A person who has a valid license under the Licensed Dietitian Act, Texas Occupations Code, Chapter 701, as a licensed dietitian or provisional licensed dietitian, or who is registered as a dietitian by the Commission on Dietetic Registration of the American Dietetic Association.

(26) [~~(29)~~] Direct ownership interest--Ownership of equity in the capital, stock, or profits of, or a membership interest in, an applicant or license holder.

(27) [~~(30)~~] Disclosable interest--Five percent or more direct or indirect ownership interest in an applicant or license holder.

(28) [~~(31)~~] Emergency situation--An impending or actual situation that:

(A) interferes with normal activities of a center or minors at a center;

(B) may:

(i) cause injury or death to a minor or individual at the center; or

(ii) cause damage to the center's property;

(D) does not include a situation that arises from the medical condition of a minor such as cardiac arrest, obstructed airway, or cerebrovascular accident.

(29) [~~(32)~~] Executive commissioner--The executive commissioner of the Texas Health and Human Services Commission.

(30) [~~(33)~~] Functional assessment--An evaluation of a minor's abilities, wants, interests, and needs related to self-care, communication skills, social skills, motor skills, play with toys or objects, growth, and development appropriate for age.

(31) [~~(34)~~] Health care provider--An individual or facility licensed, certified, or otherwise authorized to administer health care in the ordinary course of business or professional practice.

(32) [~~(35)~~] Health care setting--A location at which licensed, certified, or otherwise regulated health care is administered.

(33) [~~(36)~~] HHSC--The Texas Health and Human Services Commission.

(34) [~~(37)~~] IDT--Interdisciplinary team. Individuals who work together to meet the medical, nursing, psychosocial, and developmental needs of a minor and a minor's parent's training needs.

(35) Immediate threat to the health or safety of a minor--A situation that causes, or is likely to cause, serious injury, harm, or impairment to, or the death of a minor.

(36) [~~(38)~~] Inactive medical record--A record for a minor who was admitted by a center to receive services and was subsequently discharged by the center.

(37) [~~(39)~~] Indirect ownership interest--Any ownership or membership interest in a person that has a direct ownership interest in an applicant or license holder.

(38) [~~(40)~~] Inspection--An on-site examination or audit of a center by HHSC to determine compliance with THSC Chapter 248A and this chapter.

(39) [~~(41)~~] Isolation--The involuntary confinement of a minor in a room of a center for the purposes of infection control, assessment, and observation away from other minors in a room at the center. When in isolation, a minor is physically prevented from contact with other minors.

(40) [~~(42)~~] Joint training--Training provided by HHSC to service providers and HHSC inspectors on subjects that address the 10 most commonly cited violations of state law governing centers, as published in HHSC annual reports. HHSC determines the frequency of joint training.

(41) [~~(43)~~] License--A license to operate a center issued by HHSC under THSC, Chapter 248A, and this chapter. The term includes initial, renewal, and temporary licenses unless specifically stated otherwise.

(42) [~~(44)~~] Licensed assistant in speech-language pathology--A person who has a valid license under Texas Occupations Code, Chapter 401, as a licensed assistant in speech-language pathology and who provides speech language support services under the supervision of a licensed speech-language pathologist.

(43) [~~(45)~~] License holder--A person that holds a license to operate a center under THSC Chapter 248A and this chapter.

(44) [~~(46)~~] Life Safety Code--A publication of the National Fire Protection Association (NFPA), also known as NFPA 101, 2000 edition.

(45) [~~(47)~~] Local emergency management agencies--The local emergency management coordinator, fire, police, and emergency medical services.

(46) [~~(48)~~] Local emergency management coordinator--The person identified as the emergency management coordinator by the mayor or county judge for the geographical area in which a center is located.

(47) [~~(49)~~] LVN--Licensed vocational nurse. A person who has a valid license under Texas Occupations Code, Chapter 301, as a licensed vocational nurse.

(48) [~~(50)~~] Mechanical restraint--The use of any mechanical device, material, or equipment to restrict the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior.

(49) [~~(51)~~] Medical director--A physician who has the qualifications described in §550.307 of this chapter (relating to Medical Director Qualifications and Conditions) and has the responsibilities described in §550.308 of this chapter (relating to Medical Director Responsibilities).

(50) [~~(52)~~] Medical record--A record composed first-hand for a minor who has or is receiving services at a center.

(51) [~~(53)~~] Medically dependent or technologically dependent--The condition of an individual who, because of an acute, chronic, or intermittent medically complex or fragile condition or disability, requires ongoing, technology-based skilled nursing care prescribed by a physician to avert death or further disability, or the routine use of a medical device to compensate for a deficit in a life-sustaining body function. The term does not include a controlled or occasional medical condition that does not require continuous nursing care, including asthma or diabetes, or a condition that requires an epinephrine injection.

(52) [~~(54)~~] Medication administration record--A record used to document the administration of a minor's medications and pharmaceuticals.

(53) [~~(55)~~] Medication list--A list that includes all prescriptions, over-the-counter pharmaceuticals, and supplements that a minor is prescribed or taking, including the dosage, preparation, frequency, and the method of administration.

(54) [~~(56)~~] Minor--An individual younger than 21 years of age who is medically dependent or technologically dependent.

(55) [~~(57)~~] Mitigation--An action taken to eliminate or reduce the probability of an emergency or public health emergency or reduce an emergency's severity or consequences.

(56) [~~(58)~~] Nursing director--The individual responsible for supervising skilled services provided at a center and who has the qualifications described in §550.309 of this chapter (relating to Nursing Director and Alternate Nursing Director Qualifications and Conditions).

(57) [~~(59)~~] Nutritional counseling--Advising and assisting an adult minor or a minor's parent or family on appropriate nutritional intake by integrating information from a nutrition assessment with information on food and other sources of nutrients and meal preparation consistent with cultural background and socioeconomic status, with the goal being health promotion, disease prevention, and nutrition education. The term includes:

(A) dialogue with an adult minor or a minor's parent to discuss current eating habits, exercise habits, food budget, and problems with food preparation;

(B) discussion of dietary needs to help an adult minor or the minor's parent understand why certain foods should be included or excluded from the minor's diet and to help with adjustment to the new or revised or existing diet plan;

(C) a personalized written diet plan as ordered by the minor's prescribing physician, to include instructions for implementation;

(D) providing the adult minor or the minor's parent with motivation to help them understand and appreciate the importance of the diet plan in getting and staying healthy; or

(E) working with the adult minor or the minor's parent by recommending ideas for meal planning, food budget planning, and appropriate food gifts.

(58) [~~(60)~~] Occupational therapist--A person who has a valid license under Texas Occupations Code, Chapter 454, as an occupational therapist.

(59) [~~(61)~~] Occupational therapy assistant--A person who has a valid license under Texas Occupations Code, Chapter 454, as an occupational therapy assistant who assists in the practice of occupational therapy under the general supervision of an occupational therapist.

(60) Online portal--A secure portal provided on the HHSC website for licensure activities, including for an applicant to submit licensure applications and information.

(61) [~~(62)~~] Operating hours--The days of the week and the hours of day a center is open for services to a minor as identified in a center's written policy as required by §550.201 of this chapter (relating to Operating Hours).

(62) [~~(63)~~] Overnight--The hours between 9:00 p.m. and 5:00 a.m. during the days of the week a center operates.

(63) [~~(64)~~] Over-the-counter pharmaceuticals--A drug or formulary for which a physician's prescription is not needed for purchase or administration.

(64) [~~(65)~~] Parent--A person authorized by law to act on behalf of a minor with regard to a matter described in this chapter. The term includes:

(A) a biological, adoptive, or foster parent;

(B) a guardian;

(D) a non-parent decision-maker as authorized by Texas Family Code §32.001.

(65) [~~(66)~~] Parent company--A person, other than an individual, who has a direct 100 percent ownership interest in the owner of a center.

(66) [~~(67)~~] Person--An individual, firm, partnership, corporation, association, or joint stock association, and the legal successor thereof.

(67) [~~(68)~~] Personal care services--Services required by a minor, including:

(A) bathing;

(B) maintaining personal hygiene;

(D) grooming;

(E) dressing;

(F) feeding;

(G) eating;

(H) toileting;

(I) maintaining continence;

(J) positioning;

(K) mobility and bed mobility;

(L) transfer and ambulation;

(M) range of motion;

(N) exercise; and

(O) use of durable medical equipment.

(68) [~~(69)~~] Pharmaceuticals--Of or pertaining to drugs, including over-the-counter drugs and those requiring a physician's prescription for purchase or administration.

(69) [~~(70)~~] Pharmacist--A person who is licensed to practice pharmacy under Texas Occupations Code, Chapter 558.

(70) [~~(71)~~] Pharmacy--A facility at which a prescription drug or medication order is received, processed, or dispensed as defined in Texas Occupations Code §551.003.

(71) [~~(72)~~] Physical restraint--The use of physical force, except for physical guidance or prompting of brief duration, that restricts the free movement of all or a portion of a minor's body for the purpose of modifying or controlling the minor's behavior.

(72) [~~(73)~~] Physical therapist--A person who has a valid license under Texas Occupations Code, Chapter 453, as a physical therapist.

(73) [~~(74)~~] Physical therapist assistant--A person who has a valid license under Texas Occupations Code, Chapter 453, as a physical therapist assistant and:

(A) who assists and is supervised by a physical therapist in the practice of physical therapy; and

(B) whose activities require an understanding of physical therapy.

(74) [~~(75)~~] Physician--A person who:

(A) has a valid license in Texas to practice medicine or osteopathy in accordance with Texas Occupations Code, Chapter 155;

(B) has a valid license in Arkansas, Louisiana, New Mexico, or Oklahoma to practice medicine, who is the treating physician of a minor, and orders services for the minor, in accordance with Texas Occupations Code, Chapter 151; or

(C) is a commissioned or contract physician or surgeon who serves in the United States uniformed services or Public Health Service if the person is not engaged in private practice, in accordance with Texas Occupations Code, Chapter 151.

(75) [~~(76)~~] Place of business--An office of a center where medical records are maintained and from which services are directed.

(76) [~~(77)~~] Plan of care--A protocol of care.

(77) [~~(78)~~] Positive intervention--An intervention that is based on or uses a minor's preferences as positive reinforcement, and focuses on positive outcomes and wellness for the minor.

(78) [~~(79)~~] Pre-licensing program training--Computer-based training, available on the HHSC website, designed to acquaint center staff with licensure standards.

(79) [~~(80)~~] Premises--The term includes the center, any lots on which the center is located, any outside ground areas, any outside play areas, and the parking lot.

(80) [~~(81)~~] Preparedness--Actions taken in anticipation of a disaster including a public health disaster.

(81) [~~(82)~~] Prescribing physician--A physician who is authorized to write and issue orders for services at a center.

(82) [~~(83)~~] Progress note--A dated and signed written notation summarizing facts about services provided to a minor and the minor's response during a given period of time.

(83) [~~(84)~~] Protective device--A mechanism or treatment, including sedation, that is:

(A) used:

(i) for body positioning;

(ii) to immobilize a minor during a medical, dental, diagnostic, or nursing procedure;

(iii) to permit wounds to heal; or

(iv) for a medical condition diagnosed by a physician; and

(B) not used as a restraint to modify or control behavior.

(84) [~~(85)~~] Protocol of care--A comprehensive, interdisciplinary plan of care that includes the medical physician's plan of care, nursing care plan and protocols, psychosocial needs, and therapeutic and developmental service needs required by a minor and family served.

(85) [~~(86)~~] Psychologist--A person who has a valid license under Texas Occupations Code, Chapter 501, as a psychologist.

(86) [~~(87)~~] Psychosocial treatment--The provision of skilled services to a minor under the direction of a physician that includes one or more of the following:

(A) assessment of alterations in mental status or evidence of suicide ideation or tendencies;

(B) teaching coping mechanisms or skills;

(D) evaluation of a plan of care.

(87) [~~(88)~~] Quiet time--A behavior management technique used to provide a minor with an opportunity to regain self-control, where the minor enters and remains for a limited period of time in a designated area from which egress is not prevented.

(88) [~~(89)~~] Recovery--Activities implemented during and after a disaster response, including a public health disaster response, designed to return a center to its normal operations as quickly as possible.

(89) [~~(90)~~] Relocation--The closing of a center and the movement of its business operations to another location.

(90) [~~(91)~~] Respiratory therapist--A person who has a valid license under Texas Occupations Code, Chapter 604, as a respiratory care practitioner.

(91) [~~(92)~~] Response--Actions taken immediately before an impending disaster or during and after a disaster, including a public health disaster, to address the immediate and short-term effects of the disaster.

(92) [~~(93)~~] Restraint--Physical restraint, chemical restraint, or mechanical restraint.

(93) [~~(94)~~] RN--Registered nurse. A person who has a valid license under Texas Occupations Code, Chapter 301, to practice professional nursing.

(94) [~~(95)~~] RN delegation--Delegation of tasks by an RN in accordance with 22 Texas Administrative Code Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments).

(95) [~~(96)~~] Sedation--The act of allaying nervous excitement by administering medication that commonly induces the nervous system to calm. Sedation is a protective device.

(96) [~~(97)~~] Social worker--A person who has a valid license under Texas Occupations Code, Chapter 505, as a social worker.

(97) [~~(98)~~] Speech-language pathologist--A person who has a valid license under Texas Occupations Code, Chapter 401, as a speech-language pathologist.

(98) [~~(99)~~] Substantial compliance--A finding in which a center receives no recommendation for enforcement action after an inspection.

(99) [~~(100)~~] Supervision--Authoritative procedural guidance by a qualified person that instructs another person and assists in accomplishing a function or activity. Supervision includes initial direction and periodic inspection of the actual act of accomplishing the function or activity.

(100) [~~(101)~~] Support services--Social, spiritual, and emotional care provided to a minor and a minor's parent by a center.

(101) [~~(102)~~] THSC--Texas Health and Safety Code.

(102) [~~(103)~~] Total census--The total number of minors with active plans of care at a center.

(103) [~~(104)~~] Transition support--Planning, coordination, and assistance to move the location of services provided to a minor from a center to the least restrictive setting appropriate.

(104) [~~(105)~~] Violation--A finding of noncompliance with this chapter or THSC Chapter 248A resulting from an inspection.

(105) [~~(106)~~] Volunteer--An individual who provides assistance to a center without compensation other than reimbursement for actual expenses.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402394

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER B. LICENSING APPLICATION, MAINTENANCE, AND FEES

26 TAC §§550.101 - 550.106, 550.108 - 550.115, 550.118 - 550.123

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.101.Criteria and Eligibility for a License.

(a) To obtain a license, a person must meet the application requirements in this subchapter and meet the criteria for a license.

(b) A center must be located in Texas. The center must have a Texas mailing address.

(1) a child-care center licensed in accordance with Texas Human Resource Code, Chapter 42; or

(2) any other facility licensed by HHSC [~~DADS~~ ] or the Texas Department of State Health Services.

(d) A separate license is required for each center located on separate premises, regardless of whether the centers are owned or operated by the same person.

(e) The actual census for a center must not exceed the capacity authorized by HHSC [~~DADS~~], as indicated on the license.

(f) Before issuing a license, HHSC [~~DADS~~] considers the background and qualifications of:

(1) the applicant;

(2) a controlling person of the applicant;

(3) a person with a disclosable interest;

(4) an affiliate of the applicant;

(5) the administrator; and

(6) the chief financial officer, if the center has a chief financial officer.

(g) An applicant must affirmatively show that the center:

(1) obtained approval of building plans through plan review by the HHSC [~~DADS~~] Architectural Unit as required by Subchapter E of this chapter (relating to Building Requirements);

(2) meets local building ordinances;

(3) is approved by the local fire authority;

(4) meets the standards of the Life Safety Code and the requirements in Subchapter E of this chapter; and

(5) meets the requirements of this chapter based on an on-site health inspection by HHSC [~~DADS~~].

§550.102.General Application Requirements.

(a) An applicant may apply for a license for a center by submitting an [~~a sworn~~] application to the HHSC [~~from the DADS~~] Licensing and Credentialing Unit through the online portal. [~~An application may be obtained from the HHSC DADS website.~~]

(b) An applicant must complete the application in accordance with the instructions provided in the online portal [~~on the application and the DADS website~~].

(d) If an applicant decides not to continue the application process for a license after submitting an application and license fee, the applicant must submit a written request to HHSC [~~DADS~~] to withdraw the application. HHSC [~~DADS~~] does not refund the license fee for an application that is withdrawn, except as provided in §550.114 [~~§15.114~~] of this subchapter (relating to Time Periods for Processing All Types of License Applications).

§550.103.Building Approval.

(a) Fire authority. An applicant must receive approval from the local fire authority or, if the jurisdiction does not have a local fire authority, the state fire marshal, for an initial, renewal, change of ownership, relocation, or capacity increase license application. An applicant may submit a license application to HHSC through the online portal [~~DADS~~] before receiving fire authority approval. An applicant must submit to HHSC [~~DADS~~] a copy of a signed and dated written approval for occupancy by the local fire authority or state fire marshal that describes the center by name and address by uploading a copy through the online portal.

(b) Local health authority. An applicant for an initial, change of ownership, relocation, or capacity increase license must submit to HHSC, by uploading through the online portal, [~~DADS~~] a copy of a dated written notification to the local health authority that the applicant is submitting a license application to HHSC [~~DADS. DADS sends the local health authority a copy of DADS license renewal notification specifying the expiration date of the center's current license~~]. A local health authority may provide an evaluation to HHSC [~~DADS~~] regarding the status of the center's compliance with local codes, ordinances, or regulations. The local health authority may also recommend that HHSC [~~DADS~~] issue or deny a license to the center, but HHSC [~~DADS~~] makes the final decision regarding licensure of the center.

§550.104.Applicant Disclosure Requirements.

(a) A person that submits an initial, renewal, change of ownership, relocation, or increase in capacity license application through the online portal must follow the instructions for that application; and[:]

(1) identify the location of the place of business for which the license is sought;

(2) include documentation, signed by the appropriate local government official, stating that the center's place of business and the use of the center meet local zoning requirements;

(3) provide the name, address, and social security number of, and background and criminal history check information for:

(A) the applicant;

(B) the administrator;

(D) each controlling person of the applicant;

(4) provide the federal employer identification number or taxpayer identification number of the applicant and of each controlling person, if an applicant or controlling person is not an individual;

(5) state the assumed name under which the center will be doing business;

(6) state the maximum capacity requested for the center; and

(7) include a sworn affidavit that the applicant has complied with this chapter.

(b) For an initial license and change of ownership application, an applicant must follow the instructions for that application; and[:]

(1) submit to HHSC [~~DADS~~] evidence of the right to possess or occupy the center at the time the application is submitted, which may include:

(A) a lease agreement; or

(B) a deed; and

(2) disclose to HHSC [~~DADS~~] the name and address of the owner of the real property, including the owner of the buildings and grounds appurtenant to the center.[;]

~~[(3) submit to DADS a certificate of account status issued by the Comptroller of Public Accounts; and]~~

~~[(4) submit to DADS a certificate of incorporation issued by the Secretary of State for a corporation or a copy of the partnership agreement for a partnership.]~~

~~[(c) For a renewal application, an applicant must submit to DADS a certificate of account status issued by the Comptroller of Public Accounts.]~~

(c) [~~(d)~~] An applicant or license holder must provide to HHSC, through the online portal, [~~DADS~~] any additional information requested by HHSC [~~DADS~~ ] no later than 30 days after the date of the HHSC [~~DADS~~ ] request.

(d) [~~(e)~~] HHSC [~~DADS~~ ] may require an applicant to disclose information relating to the fiduciary-appointed administrator of the center.

§550.105.Initial License Application Procedures and Issuance.

(a) The center's administrator must complete pre-licensing program training before an applicant may submit an initial application for a license.

(b) An applicant for an initial license must submit to HHSC through the online portal:

(1) a complete and correct application including all documents and information that HHSC requires as part of the application process;

(2) the correct license fee established in §550.112 [~~§15.112~~] of this subchapter (relating to Licensing Fees);

(3) a letter of credit for $250,000 from a bank that is insured by the Federal Deposit Insurance Corporation, or other documentation acceptable to HHSC, to demonstrate an applicant's financial viability; and

(4) all other documents described in the instructions provided on the application and on the HHSC website.

(c) After HHSC receives an application for an initial license and the correct license fee, HHSC reviews the application and notifies the applicant if additional information is needed to complete the application.

(d) An applicant must submit written notice to HHSC that the center is ready for a Life Safety Code inspection by uploading the notification through the online portal.

(1) The written notice must be submitted:

(A) with the application; or

(B) no later than 120 days after the HHSC Licensing and Credentialing Section receives the application.

(2) After HHSC receives the written notice for a Life Safety Code inspection and an applicant has satisfied the application submission requirements, HHSC staff conducts an on-site Life Safety Code inspection.

(e) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny [~~denies~~] the license application.

(f) If a center meets the building requirements in Subchapter E of this chapter, the center may admit no more than three minors. After a [~~If the~~] center admits one [a] minor, the applicant must send written notice to HHSC indicating the center is ready for a health inspection by uploading the notice through the online portal. The center must submit the request for the [~~The~~] health inspection [~~request must be submitted~~] no later than 120 days after the date the center meets the building requirements.

(1) After HHSC receives the request for the health inspection, HHSC conducts an on-site health inspection to determine compliance with this chapter.

(2) If the center fails to comply with this chapter and fails to implement an approved written plan of correction no later than 120 days after the date of the initial health inspection, HHSC Licensing proposes to deny [~~denies~~] the license application.

(g) If an applicant receives a notice from HHSC that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If the applicant fails to timely submit the requested information, HHSC Licensing proposes to deny [~~denies~~ ] the application. If HHSC Enforcement denies the application, HHSC does not refund the license fee.

(h) HHSC issues an initial license if it determines that an applicant has met the provisions of this chapter and THSC Chapter 248A.

(i) The issuance of an initial license constitutes notice from HHSC to the center of the approval of the application.

(j) HHSC issues a center license to the license holder named on the license at the place of business listed on the license. The license is not transferable or assignable.

(k) The license includes:

(1) the license holder's name;

(2) the name of the center;

(3) the center's place of business;

(4) the center's licensed capacity; and

~~[(5) a statement that the center provides services to minors for 12 hours or less in a 24-hour period but no overnight care; and]~~

(5) [~~(6)~~] the effective date of the license.

(l) HHSC Licensing may propose to deny an application for an initial license if the applicant, a controlling person, or a person required to submit background and qualification information fails to meet the criteria for a license established in §550.101 [~~§15.101~~] of this subchapter (relating to Criteria and Eligibility for a License) or for any reason specified in §550.115 [~~§15.115~~] of this subchapter (relating to Criteria for Denial of a License).

(m) If HHSC denies an application for an initial license, HHSC sends the applicant written notice of the denial and informs the applicant of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act).

(n) An initial license expires on the third anniversary after the effective date of the initial license.

§550.106.Renewal License Application Procedures and Issuance.

(a) A center license expires on the third anniversary after the effective date on the license. To renew a license, a license holder must submit a renewal application to HHSC through the online portal before the expiration date of the current license. HHSC sends written notice of expiration of a license to the license holder through the online portal at least 120 days before the expiration date of a license. [~~The written notice includes instructions for completing the renewal application.~~]

(b) A license holder must comply with the requirements in §550.102 [~~§15.102~~] of this subchapter (relating to General Application Requirements) and §550.114 [~~§15.114~~] of this subchapter (relating to Time Periods for Processing All Types of License Applications) to renew a license.

(c) In accordance with Texas Government Code, §2001.054, HHSC considers that a license holder meets the renewal application submission deadline if the license holder submits through the online portal:

(1) no later than 60 days before the expiration date of the current license:

(A) a complete application for renewal or an incomplete application for renewal with a letter explaining the circumstances that prevented the inclusion of the missing information; and

(B) the correct license fee established in §550.112 [~~§15.112~~] of this subchapter (relating to Licensing Fees); or

(2) during the 60-day period ending on the date the current license expires:

(A) a complete application for renewal or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;

(B) the correct license fee established in §550.112 [~~§15.112~~] of this subchapter; and

(d) HHSC reviews a renewal application and notifies the license holder if additional information is needed to complete the application.

(e) It is the license holder's responsibility to ensure that the application is timely received by HHSC. Failure to submit a timely and sufficient renewal application with the correct license fee through the online portal will result in the expiration of the license.

(f) If a license holder submits a renewal application to HHSC through the online portal [~~that is postmarked~~] after the expiration date of the license, HHSC denies the renewal application and does not refund the renewal license fee. The license holder is not eligible to renew the license and must cease operation on the date the license expires. A license holder whose license expires must apply for an initial license in accordance with §550.105 [~~§15.105~~] of this subchapter (relating to Initial License Application Procedures and Issuance).

(g) HHSC issues a renewal license after determining that an applicant and the center have met the provisions of THSC §248A.002 and this chapter.

(h) The issuance of a renewal license constitutes notice from HHSC to the center that the application is approved.

(i) A renewal license issued in accordance with this chapter expires on the third anniversary after the effective date on the license.

(j) HHSC may pend action on an application for the renewal of a license for up to six months if the center is not in compliance with THSC §248A.002 and this chapter based on an on-site inspection.

(k) HHSC Licensing may propose to deny an application for the renewal of a license if an applicant, controlling person, or any person required to submit background and qualification information fails to meet the criteria for a license established in §550.101 [~~§15.101~~] of this subchapter (relating to Criteria and Eligibility for a License) or for any reason specified in §550.115 [~~§15.115~~] of this subchapter (relating to Criteria for Denial of a License).

(l) Before denying a license renewal application, HHSC Enforcement gives the license holder:

(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and

(2) an opportunity to show compliance with all the requirements of THSC Chapter 248A and this chapter to retain the license.

(m) To request an opportunity to show compliance, the license holder must send a written request to HHSC. The request must:

(1) be postmarked no later than 10 days after the date of notice from HHSC of the proposed action and received by HHSC no later than 10 days after the date of the postmark; and

(2) contain documentation that refutes HHSC allegations specifically.

(n) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC gives the license holder a written affirmation or reversal of the proposed action.

(o) If HHSC Enforcement denies an application for a renewal license, HHSC sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC hearing rules found in Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act).

§550.108.Change of Ownership License Application Procedures and Issuance and Notice of Changes.

(a) For purposes of this section, a temporary change of ownership license is a temporary license issued to an applicant who proposes to become the new operator of a center that exists on the date the applicant submits a change of ownership license application [~~is submitted~~].

(b) A center license is not assignable or transferable. The applicant (prospective new license holder) must obtain a temporary change of ownership license followed by an initial three-year license in accordance with this section. When HHSC [~~the Texas Health and Human Services Commission (HHSC)~~] approves the change of ownership by issuing a temporary change of ownership license to the applicant (prospective new license holder) [~~new license holder~~], the current license holder's license becomes invalid as of the effective date of the change of ownership indicated in the application. Between the effective date of the change of ownership and the issuance of the temporary change of ownership license, the current license holder remains responsible under its license; however, the applicant may operate a center on behalf of the current license holder during such period of time.

(1) a complete application for a license in accordance with HHSC instructions and §550.101 of this subchapter (relating to Criteria and Eligibility for a License) or an incomplete application with a letter explaining the circumstances that prevented the inclusion of the missing information;

(2) the application fee, in accordance with §550.112 of this subchapter (relating to Licensing Fees);

(3) a letter of credit for $250,000 from a bank that is insured by the Federal Deposit Insurance Corporation, or other documentation acceptable to HHSC, to demonstrate the applicant's financial viability; and

(4) a signed and notarized Change of Ownership Transfer Affidavit HHSC Form 1092 from the applicant and the center's current license holder of intent to transfer operation of the center from the current license holder to the applicant, beginning on the change of ownership effective date specified on the change of ownership application.

(d) HHSC Licensing may propose to deny issuance of a change of ownership license if the applicant, a controlling person, or any person disclosed in the application fails to meet the criteria for a license established in §550.101 of this subchapter or for any reason specified in §550.115 of this subchapter (relating to Criteria for Denial of a License).

(e) To avoid a center operating without a license, an applicant must submit all items in subsection (c) of this section in accordance with HHSC instructions at least 30 days before the anticipated date of the change of ownership specified on the change of ownership application [~~in accordance with HHSC instructions~~], unless the 30-day notice requirement is waived in accordance with subsection (f) of this section.

(f) HHSC may waive the 30-day notice required by subsection (e) of this section if:

(1) the applicant presents evidence to HHSC demonstrating that an eviction of the center or a foreclosure of the property from which the center operates is imminent and that circumstances [~~circumstance~~] prevented the timely submission of the items specified in subsection (c) of this section; or

(2) HHSC, in its sole discretion, determines that circumstances are present that threaten a minor's health, safety, or welfare and necessitate waiver of timely submission of the items specified in subsection (c) of this section.

(g) Upon HHSC approval of the items specified in subsection (c) of this section, HHSC issues a temporary change of ownership license to the applicant if HHSC finds that the applicant, all controlling persons, and all persons disclosed in the application satisfy the requirements in §§550.101(a) and (f) of this subchapter, 550.104 of this subchapter (relating to Applicant Disclosure Requirements), and 550.115 of this subchapter.

(1) The issuance of a temporary change of ownership license constitutes [~~HHSC's~~] official written notice by HHSC to the center [~~facility~~] of the approval of the application for a change of ownership.

(2) The effective date of the temporary change of ownership license is the date requested in the application and cannot precede the date the application is received by HHSC through the online portal.

(h) A temporary change of ownership license expires on the earlier of:

(1) 90 days after its effective date or the last day of any extension HHSC provides in accordance with subsection (i) of this section; or

(2) the date HHSC issues a three-year license in accordance with subsection (l) of this section.

(i) HHSC, in its sole discretion, may extend the term of a temporary change of ownership license by 90 days based upon extenuating circumstances.

(j) HHSC conducts an on-site health inspection to verify compliance with the licensure requirements after issuing a temporary change of ownership license. HHSC may conduct a desk review instead of an on-site health inspection after issuing a temporary change of ownership license if:

(1) less than 50 percent of the direct or indirect ownership interest in the former license holder changed, when compared to the new license holder; or

(2) every person with a disclosable interest in the new license holder had a disclosable interest in the former license holder.

(k) HHSC, in its sole discretion, may conduct an on-site Life Safety Code inspection after issuing a temporary change of ownership license.

(l) If an applicant and all other persons disclosed in the application satisfy the requirements of §§550.101(a) and (f), 550.104, and 550.115 of this subchapter for a license, and the center passes the change of ownership health inspection as described in subsection (j) of this section, HHSC issues a three-year license. The effective date of the three-year license is the same date as the effective date of the change of ownership and cannot precede the date the application for a license was received through the online portal.

(m) If a license holder changes its name but does not undergo a change of ownership, the license holder must notify HHSC and submit documentation evidencing a legal name change by submitting an application through the online portal. On receipt of the notice and documentation, HHSC reissues the current license in the license holder's new name.

(n) If a license holder adds an owner with a disclosable interest, but the license holder does not undergo a change of ownership, the license holder must notify HHSC of the addition no later than 30 days after the addition of the owner by submitting an application through the online portal.

§550.109.Increase in Capacity.

(a) A license holder must not increase a center's licensed capacity without approval from HHSC [~~DADS~~].

(b) The license holder must submit an application for an increase in capacity in accordance with §550.102 [~~§15.102~~] of this subchapter (relating to General Application Requirements) and the correct fee required in §550.112 [~~§15.112~~] of this subchapter (relating to Licensing Fees) through the online portal.

(1) arrange for an inspection of the center by the local fire marshal or the state fire marshal; and

(2) submit written evidence of the fire marshal's approval to HHSC that describes the center by name and address by uploading a copy through the online portal.

~~[(c) The license holder must arrange for an inspection of the center by the local fire marshal and provide written evidence of the fire marshal's approval to DADS.]~~

(d) An applicant must send written notice to HHSC [~~DADS~~] indicating that the center is ready for a Life Safety Code inspection by uploading the notice through the online portal.

(1) The written notice must be submitted:

(A) with the application; or

(B) no later than 120 days after HHSC [~~DADS~~ ] Licensing and Credentialing Unit receives the application.

(2) After HHSC [~~DADS~~] receives the written notice for a Life Safety Code inspection and an applicant has satisfied the application submission requirements, HHSC [~~DADS~~] staff conducts an on-site Life Safety Code inspection.

(e) If an applicant receives a notice from HHSC [~~DADS~~] that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If an applicant fails to submit the requested information no later than 30 days after the notice date, HHSC [~~DADS~~] considers the application incomplete and proposes to deny [~~denies~~] the application. If HHSC [~~DADS~~] denies the application, HHSC [~~DADS~~] does not refund the license fee.

(f) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny [~~DADS denies~~] the application for a license.

(g) After a center has met Life Safety Code requirements, HHSC [~~DADS~~] conducts an on-site health inspection.

(h) HHSC [~~DADS~~] issues a new license with an increased capacity if HHSC [~~DADS~~] determines that the center is in compliance with this chapter.

(i) If an applicant decides not to continue the application process after submitting the application and correct license fee, an applicant must submit to HHSC [~~DADS~~] a written request to withdraw the application. HHSC [~~DADS~~] does not refund the license fee.

(j) Before denying an application for an increase in capacity, HHSC Enforcement [~~DADS~~] gives the license holder:

(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and

(2) an opportunity to show compliance with all the requirements of the THSC Chapter 248A and this chapter to retain the license.

(k) To request an opportunity to show compliance, the license holder must send a written request to HHSC [~~DADS~~]. The request must:

(1) be postmarked no later than 10 days after the date of the HHSC [~~DADS~~] notice of proposed action and received by HHSC [~~DADS~~] no later than 10 days after the date of the postmark; and

(2) contain documentation that refutes the [~~DADS~~] allegations [~~superficially~~].

(l) The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC [~~DADS~~] used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC [~~DADS~~] gives the license holder a written affirmation or reversal of the proposed action.

(m) If HHSC [~~DADS~~] denies an application for an increase in capacity, HHSC [~~DADS~~] sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with [~~Texas Health and Human Services Commission rules found at~~ ] 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC [~~DADS~~] hearing rules found in Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act).

§550.110.Decrease in Capacity.

(a) A license holder who wishes to decrease the licensed capacity of the center must provide written notification to HHSC by submitting a capacity change application through the online portal [~~DADS~~]. The application [~~written notification~~] must indicate the new licensed capacity for the center.

(b) After HHSC [~~DADS~~] receives the application, HHSC [~~written notification, DADS~~] issues a new license with the new licensed capacity [~~as indicated in the written notification~~].

§550.111.Relocation.

(a) Relocation is the closing of a center and the movement of its business operations to another location.

(b) A license holder must not relocate a center or provide services to a minor at a new location without prior approval from HHSC [~~DADS~~].

(c) The license holder must continue to maintain the license at the current location and must continue to meet all requirements for operation of the center until HHSC approves [~~DADS has approved~~] the relocation.

(d) Before a relocation, the license holder must submit a relocation [an] application [~~for an initial license~~] for the new location [~~in accordance with §15.105 of this subchapter (relating to Initial License Application Procedures and Issuance)~~] and the correct fee for a relocation [~~an initial license~~] required in §550.112 [~~§15.112~~ ] of this subchapter (relating to Licensing Fees) through the online portal.

(e) The license holder must:

(1) arrange for an inspection of the center by the local fire marshal or state fire marshal; and

(2) submit written evidence of the fire marshal's approval to HHSC that describes the center by name and address by uploading a copy through the online portal.

~~[(e) The license holder must arrange for an inspection of the center by the local fire marshal and provide written evidence of the fire marshal's approval to DADS.]~~

(f) An applicant must send written notice to HHSC [~~DADS~~] indicating that the center is ready for a Life Safety Code inspection.

(1) The written notice must be submitted through the online portal:

(A) with the application; or

(B) no later than 120 days after HHSC [~~DADS~~ ] Licensing and Credentialing Unit receives the application.

(g) If an applicant receives a notice from HHSC [~~DADS~~] that some or all of the information is missing or incomplete, an applicant must submit the requested information no later than 30 days after the date of the notice. If an applicant fails to submit the requested information no later than 30 days after the notice date, HHSC Licensing [~~DADS~~] considers the application incomplete and proposes to deny [~~denies~~] the application. If HHSC Enforcement [~~DADS~~] denies the application, HHSC [~~DADS~~] does not refund the license fee.

(h) The center must meet the building requirements described in Subchapter E of this chapter (relating to Building Requirements). If a center fails to meet the building requirements and fails to implement an approved written plan of correction no later than 120 days after the initial Life Safety Code inspection, HHSC Licensing proposes to deny [~~DADS denies~~] the application for a license.

~~[(i) After a center has met Life Safety Code requirements, DADS conducts an on-site health inspection.]~~

(i) [~~(j)~~] Following Life Safety Code approval by HHSC [~~DADS~~], the license holder must notify HHSC [~~DADS~~] of the date the business operations will be relocated.

(j) [~~(k)~~] HHSC [~~DADS~~ ] issues a license for the new center if the new center meets the requirements in this chapter. The effective date of the license is the date all business operations are relocated.

(k) [~~(l)~~] The issuance of a license constitutes HHSC [~~DADS~~] approval of the relocation.

(l) [~~(m)~~] The license for the current location becomes invalid upon issuance of the new license for the new location.

(m) [~~(n)~~] If an applicant decides not to continue the application process after submitting the application and correct license fee, an applicant must submit to HHSC [~~DADS~~] a written request to withdraw the application. HHSC [~~DADS~~] does not refund the license fee.

(n) [~~(o)~~] Before denying an application for relocation, HHSC Enforcement [~~DADS~~] gives the license holder:

(1) notice by personal service or by registered or certified mail of the facts or conduct alleged to warrant the proposed action; and

(2) an opportunity to show compliance with all the requirements of THSC Chapter 248A and the Chapter to retain the license.

(o) [~~(p)~~] To request an opportunity to show compliance, the license holder must send a written request to HHSC [~~DADS~~]. The request must:

(1) be postmarked no later than 10 days after the date of HHSC [~~DADS~~] notice of proposed action and received by HHSC [~~DADS~~] no later than 10 days after the date of the postmark; and

(2) contain documentation that refutes HHSC [~~DADS~~] allegations specifically.

(p) [~~(q)~~] The opportunity to show compliance is limited to a review of documentation submitted by the license holder and information HHSC [~~DADS~~] used as the basis for the proposed action. The opportunity to show compliance is not an administrative hearing. HHSC [~~DADS~~] gives the license holder a written affirmation or reversal of the proposed action.

(q) [~~(r)~~] If HHSC [~~DADS~~ ] denies an application for relocation, HHSC [~~DADS~~] sends the license holder a written notice of the denial and informs the license holder of the right to request an administrative hearing to appeal the denial. The administrative hearing is held in accordance with Texas Health and Human Services Commission rules found in 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and HHSC [~~DADS~~] hearing rules found in Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act).

§550.112.Licensing Fees.

(a) The schedule of fees for licensure of a center is as follows:

(1) initial license fee (includes changes of ownership and relocation)--$2,625 [~~$2625~~];

(2) renewal license fee--$2,625 [~~$2625~~]; and

(3) increase in capacity--$1,312.50 [~~$1312.50~~].

(b) HHSC does not waive the license fee for a change of ownership application despite a demonstration of the circumstances referenced in §550.108(f) [~~§15.108(f)~~] of this subchapter (relating to Change of Ownership License Application Procedures and Issuance and Notice of Changes). HHSC may waive the timely submission of an application for a change of ownership in accordance with §550.108(f) [~~§15.108(f)~~] of this subchapter.

(c) The late fee established in §550.106 [~~§15.106~~] of this subchapter (relating to Renewal License Application Procedures and Issuance) is $50 per day to a license holder who submits a renewal application after the date as described at §550.106 [~~§15.106~~] of this subchapter, except that the total amount of a late fee may not exceed $500.00.

(d) HHSC does not consider an application as submitted until an applicant pays the correct license fee as required in this section. The fee must accompany the application.

(e) A fee paid to HHSC is not refundable, except as provided by §550.114 [~~§15.114~~] of this chapter (relating to Time Periods for Processing All Types of License Applications).

(f) HHSC accepts payment according to methods described in the application instructions [~~provided on the HHSC website~~].

§550.113.Plan Review Fees.

(a) A center must pay a fee to HHSC [~~DADS~~] for its review of plans for new buildings, additions, conversion of buildings not licensed by HHSC [~~DADS~~], or remodeling of existing licensed facilities as described on the HHSC [~~DADS~~] website.

(b) The fee schedule follows:

(1) facilities--new construction:

(A) single-story facilities--$2,000; and

(B) multiple-story facilities--$2,500; and

(2) additions or remodeling of existing licensed facilities--2 percent of construction cost with a $500 minimum fee and a maximum not to exceed $2,000.

§550.114.Time Periods for Processing All Types of License Applications.

(a) The date of an application is the date the HHSC [~~DADS~~] Licensing and Credentialing Unit receives the application and the correct license fee as required in §550.112 [~~§15.112~~] of this subchapter (relating to Licensing Fees).

(b) HHSC [~~DADS~~] considers an application for an initial license complete when HHSC [~~DADS~~ ] accepts the information described in §550.105 [~~§15.105~~] of this subchapter (relating to Initial License Application Procedures and Issuance).

(c) HHSC [~~DADS~~] considers an application for a renewal license complete when HHSC [~~DADS~~ ] accepts the information described in §550.106 [~~§15.106~~] of this subchapter (relating to Renewal License Application Procedures and Issuance). A center may continue to operate during the renewal application process in accordance with §550.106 [~~§15.106~~] of this subchapter.

(d) HHSC [~~DADS~~] considers an application for a change of ownership license complete when HHSC [~~DADS~~] accepts the information described in §550.108 [~~§15.108~~] of this subchapter (relating to Change of Ownership License Application Procedures and Issuance and Notice of Changes).

(e) HHSC [~~DADS~~] reviews an application for a license no later than 45 days after the date the HHSC [~~DADS~~] Licensing and Credentialing Unit receives the application.

(f) If an applicant receives a notice through the online portal from HHSC [~~DADS~~] that some or all of the information required by this chapter is missing or incomplete, an applicant must submit the required information through the online portal no later than 30 days after the date of the notice. If an applicant fails to submit the required information no later than 30 days after the notice date, HHSC Licensing [~~DADS~~] considers the application incomplete and proposes to deny [~~denies~~] the application. If HHSC Enforcement [~~DADS~~] denies the application, HHSC Licensing [~~DADS~~] does not refund the license fee.

(g) HHSC Licensing proposes to deny [~~DADS denies~~] an application that remains incomplete 120 days after the date that the HHSC [~~DADS~~] Licensing and Credentialing Unit receives the application.

(h) HHSC [~~DADS~~] issues a license no later than 30 days after HHSC [~~DADS~~] determines that an applicant and the center have met all licensure requirements referenced in §550.105 [~~§15.105~~] and §550.106 [~~§15.106~~] of this subchapter, as applicable.

(i) If HHSC [~~DADS~~] does not process an application in the time period described in subsections (e) and (h) of this section, an applicant may request reimbursement of the license fee paid. The applicant must submit the reimbursement request through the online portal [~~following the instructions on the DADS website~~].

(j) If HHSC [~~DADS~~] does not agree that the established time period for processing an application described in subsection (e) of this section has been violated or finds that good cause existed for exceeding the established time period, HHSC denies [~~DADS will deny~~] the request.

(k) Good cause for exceeding the established time period exists if:

~~[(1) DADS receives an application during the time period of September 1, 2014 through June 30, 2015;]~~

(1) [~~(2)~~] the number of applications to be processed exceeds by 15 percent or more the number processed in the same fiscal quarter of the preceding year [~~effective when DADS has obtained and published two quarters of application data~~];

(2) [~~(3)~~] HHSC [~~DADS~~ ] must rely on another public or private entity to process all or a part of the application received by HHSC [~~DADS~~], and the delay is caused by that entity; or

(3) [~~(4)~~] other conditions existed giving good cause for exceeding the established time period.

(l) If HHSC [~~DADS~~] denies the request for reimbursement, an applicant may request that the executive [~~DADS~~] commissioner resolve the dispute. An applicant must send a written statement to the executive [~~DADS~~] commissioner describing the request for reimbursement and the reason for the request. The executive [~~DADS~~] commissioner reviews [~~will review~~] the request and notifies [~~notify~~] an applicant in writing of the decision.

§550.115.Criteria for Denial of a License.

(a) HHSC [~~DADS~~] may deny an application for an initial center license or for renewal of a license for:

(1) a violation of the THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;

(2) an intentional or negligent act by the center or an employee of the center that HHSC [~~DADS~~] determines significantly affects the health or safety of a minor served at the center;

(3) use of drugs or intoxicating liquors to an extent that affects the license holder's or applicant's professional competence;

(4) a felony conviction, including a finding or verdict of guilty, an admission of guilt, or a plea of nolo contendere, in this state or in any other state of any person required by this chapter to undergo a background and criminal history;

(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception, committed by any person listed on the application;

(6) a license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed on the application;

(7) criteria described in Chapter 560 [99] of this title (relating to Denial or Refusal of License) that applies to any person required by this chapter to undergo a background and criminal history check;

(8) aiding, abetting, or permitting a substantial violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;

(9) a license holder or applicant's failure to provide the required information as requested on the application or in follow-up to the review of the application;

(10) a license holder or applicant who knowingly:

(A) submits false or intentionally misleading statements to HHSC [~~DADS~~] on an application;

(B) uses subterfuge or other evasive means of filing an application;

(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or

(D) conceals a material fact on an application;

(11) a person listed on the application failing to pay the following fees, taxes, and assessments when due:

(A) licensing fees as described in §550.112 [~~§15.112~~] of this subchapter (relating to Licensing Fees);

(B) franchise taxes, if applicable; and

(12) a person listed on the application having a history of any of the following actions during the five-year period preceding the date of the application:

(A) operation of a facility in Texas or another state or jurisdiction that has been decertified or had its contract canceled under the Medicare or Medicaid program;

(B) federal or state Medicare or Medicaid sanctions or penalties;

(D) eviction in Texas or another state or jurisdiction involving any property or space used as a center; or

(E) suspension in Texas or another state or jurisdiction of a license to operate a health facility, long-term care facility, assisted living facility, or a similar facility, or a center.

(b) HHSC [~~DADS~~]:

(1) denies a license to an applicant to operate a center if an applicant has on the date of the application:

(A) a debarment or exclusion from the Medicare or Medicaid programs by the federal government or a state; or

(B) a court injunction prohibiting an applicant or manager from operating a center; and[.]

(2) may deny a license to an applicant to operate a new center if an applicant has a history of any of the following actions at any time preceding the date of the application:

(A) revocation of a license to operate a health care facility, long-term care facility, assisted living facility or similar facility, or center in any state;

(B) surrender of a license in lieu of revocation or while a revocation hearing is pending;

(C) expiration of a license while a revocation action is pending and the license is surrendered without an appeal of the revocation or an appeal is withdrawn; or

(D) probation period placed on a license to operate a center.

(c) HHSC [~~DADS~~] may consider exculpatory information provided by any person described in §550.101(f) [~~§15.101(f)~~] of this subchapter (relating to Criteria and Eligibility for a License) and grant a license if HHSC [~~DADS~~] finds that person able to comply with THSC Chapter 248A and this chapter.

(d) In determining the denial of a license, HHSC [~~DADS~~] considers all final actions taken against an applicant or license holder whether issued by HHSC [~~DADS~~] or another state or federal agency. An action is final when administrative and judicial remedies are exhausted. All actions, whether pending or final, must be disclosed.

(e) If an applicant owns multiple centers or other facility types, HHSC [~~DADS~~] examines the overall record of compliance in all of the centers or other facilities [~~types~~] and agencies. An overall record poor enough to deny issuance of a new license does [~~will~~] not preclude the renewal of licenses of individual centers with satisfactory records.

(f) If HHSC [~~DADS~~] denies an application for a license, HHSC sends [~~or refuses to issue a renewal of a license,~~] an applicant written notice of the denial and informs the applicant of the right to [~~or license holder may~~] request an administrative [a ] hearing to appeal the denial. The administrative hearing is held in accordance with [~~by complying with the Texas Health and Human Services Commission's rules for hearings found in~~] 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and [~~DADS rules for hearings found in~~] Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act). [~~An administrative hearing is conducted in accordance with Texas Government Code, Chapter 2001; 1 TAC Chapter 357, Subchapter I; and Chapter 91 of this title.~~]

§550.118.Reporting Changes in Application Information.

If certain information provided on an initial or renewal application changes after HHSC [~~DADS~~] issues the license, a center must report the change to HHSC [~~DADS~~] by submitting a change application through the online portal [~~following the instructions on the DADS website for reporting a change~~]. For requirements on reporting a change regarding:

(1) the administrator, chief financial officer, and controlling person, a center must comply with §550.119 [~~§15.119~~] of this subchapter [~~division~~] (relating to Notification Procedures for a Change in Administration and Management) and §559.302 [~~§15.302~~] of this chapter (relating to Organizational Structure and Lines of Authority);

(2) the center's contact information, a center must comply with §550.120 [~~§15.120~~] of this subchapter (relating to Notification Procedures for a Change of [in] Contact Information);

(3) the center's operating hours, a center must comply with §550.121 [~~§15.121~~] of this subchapter (relating to Notification Procedures for a Change in Operating Hours); and

(4) name (legal entity or doing business as), a center must comply with §550.122 [~~§15.122~~] of this subchapter (relating to Notification Procedures for a Name Change).

§550.119.Notification Procedures for a Change in Administration and Management.

(a) If a change occurs in the following management staff, a center must report the change to HHSC by submitting notification through the application in the online portal [~~submit written notice to DADS~~] no later than seven days after the date of a change in:

(1) administrator;

(2) chief financial officer; or

(3) controlling person, as defined in §550.5 [~~§15.5~~] of this chapter (relating to Definitions), including:

(A) a change of five percent or more of the controlling interest of a limited partner in a limited partnership or the addition of a controlling person to the limited partnership; or

(B) a change of five percent or more of the controlling interest in a for-profit corporation or limited liability company.

(b) A change in the management staff listed in subsection (a) of this section requires HHSC review [~~DADS evaluation~~ ] and approval. HHSC [~~DADS~~] reviews the required documents and information submitted. HHSC [~~DADS~~] provides notification to a center through the application in the online portal if a person listed in subsection (a) [~~(a)(1) - (6)~~] of this section does not meet the required qualifications described in §550.101 of this chapter (relating to Criteria and Eligibility for a License).

§550.120.Notification Procedures for a Change of Contact Information.

A center must report a change in contact information [~~submit written notice~~] to HHSC by submitting a change application through the online portal [~~DADS~~] no later than seven days after a change in the center's:

(1) telephone number; or

(2) mailing address, if different from the physical location.

§550.121.Notification Procedures for a Change in Operating Hours.

A center must report a change in operating hours [~~submit written notice~~] to HHSC by submitting a change application through the online portal [~~DADS~~] no later than seven days after a change in the center's operating hours.

§550.122.Notification Procedures for a Name Change.

(a) If a center intends to change the name of its legal entity or assumed name, but does not undergo a change of ownership as defined in §550.107 [~~§15.107~~] of this subchapter (relating to Change of Ownership), the center must report the name change to HHSC by submitting a change application through the online portal [~~DADS~~] no later than seven days after the effective date of the name change.

(b) If a center changes its name but does not undergo a change of ownership, the license holder must notify HHSC through submission of a change application through the online portal [~~DADS~~] and submit a copy of a certificate of amendment from the Office of the Secretary of State. After HHSC [~~DADS~~] receives the certificate of amendment and approves the change application, a license is issued in the license holder's new name.

§550.123.Request and Issuance of Temporary License.

(a) An applicant for an initial license under §550.105 [~~§15.105~~] of this subchapter (relating to Initial License Application Procedures and Issuance) may request that HHSC [~~DADS~~] issue a temporary license pending review by HHSC [~~DADS review~~] of the applicant's application for an initial license.

(b) To request a temporary license, the applicant must submit an application for a temporary license to the HHSC Licensing and Credentialing [~~DADS Provider Licensure and Certification~~] Unit through the online portal [~~a written request for a temporary license~~] and upload a copy of the applicant's policies, procedures and staffing plans that demonstrate compliance with the licensing standards of this chapter.

(1) determines that the applicant has submitted an application for an initial license in accordance with §550.105 [~~§15.105~~] of this subchapter;

(2) determines that the applicant meets the building requirements of Subchapter E of this chapter; and

(3) approves the applicant's policies, procedures and staffing plans submitted in accordance with subsection (b) of this section.

(d) If HHSC [~~DADS~~] issues a temporary license, the center may admit no more than six minors to the center until the temporary license expires or terminates.

(e) The issuance of a temporary license constitutes HHSC [~~DADS~~] notice to the applicant of the approval of the temporary license request.

(f) A temporary license expires on the earlier of:

(1) 90 days after HHSC [~~DADS~~] issues the temporary license or the last day of any extension HHSC [~~DADS~~] grants in accordance with subsection (g) of this section;or

(2) the date HHSC [~~DADS~~] issues an initial license.

(g) A temporary license holder may request that HHSC [~~DADS~~] extend the term of a temporary license by 90 days. To request an extension, the license holder must submit to the HHSC [~~DADS~~] Provider License and Certification Unit, a [~~written~~] request for an extension through the online portal. If HHSC [~~DADS~~] receives the request at least 30 days before the date the temporary license expires, HHSC [~~DADS~~] extends the term of the license for 90 days and notifies the temporary license holder of the extension in writing. HHSC [~~DADS~~] grants an applicant only one temporary license extension for a center.

(h) A temporary license holder must comply with the requirements of THSC Chapter 248A and the licensing standards of this chapter for the term of the temporary license. HHSC [~~DADS~~ ] may take the enforcement action described in Subchapter G of this chapter (relating to Enforcement) if the temporary license holder does not comply with THSC Chapter 248A or this chapter.

(i) HHSC [~~DADS~~] may visit or conduct an investigation or inspection of a center owned or operated by a temporary license holder, as described in Subchapter F of this chapter (relating to Inspections and Visits).

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402395

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER C. GENERAL PROVISIONS

DIVISION 1. OPERATIONS AND SAFETY PROVISIONS

26 TAC §§550.202, 550.203, 550.205 - 550.207, 550.210, 550.211

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.202.Suspension of Operations.

(a) Suspension of operations occurs when a center suspends its normal business operations for five or more consecutive days due to:

(1) a scheduled closing of the center when a center has at least 45 days advance notice of the need to close the center; or

(2) an unscheduled closing of the center when a center has less than 45 days but more than 15 days advance notice of the need to close the center.

(b) A suspension of operations may not exceed the expiration date of the licensure period.

(1) provide written notification to an adult minor or a minor's parent at least 30 days before the suspension of operations begins that includes:

(A) the start and end date of the suspension;

(B) instructions for obtaining a minor's medical records before and during the suspension for all services provided at the center; and

(C) information about the available options to transfer, discharge, or put a minor's services on hold depending on the needs of the minor;

(2) assist a parent or an adult minor with finding alternative services during the suspension;

(3) discharge, transfer or put a minor's services on hold in accordance with §550.608 [~~§15.608~~] of this subchapter [~~chapter~~] (relating to Discharge or Transfer Notification);

(4) ensure coordination of services for the minor's other service providers;

(5) notify the minor's physician at least 30 days before the suspension of operations begins;

(6) provide written notification to HHSC through the online portal [~~DADS~~] at least 30 days before the suspension of operations begins; [~~and~~]

(7) post a notice, in a location visible outside of the center for the duration of the suspension, that provides information about the suspension of operations, including:

(A) the start and end date of the suspension; and

(B) how to obtain a minor's records during the suspension;

(8) leave an outgoing message, on the center's answering machine or other similar electronic mechanism or with an answering service, that provides the information in paragraph (7) of this subsection; and

(9) notify HHSC [~~DADS~~] in writing within seven days after resuming normal business operations.

(d) If a center suspends operations due to an unscheduled closing of the center, the center must:

(1) provide oral and written notification to a minor's parent no later than 15 days before the suspension of operations begins that includes:

(A) the start and estimated end date of the suspension;

(B) instructions for obtaining a minor's medical records before and during the suspension for all services provided at the center; and

(C) information about the available options to transfer, discharge, or put a minor's services on hold depending on the needs of the minor;

(2) assist a parent or an adult minor with finding alternative services during the suspension;

(3) discharge, transfer or put the minor's services on hold in accordance with §550.608 [~~§15.608~~] of this subchapter [~~chapter~~];

(4) ensure coordination of services with the minor's other service providers;

(5) notify the minor's physician no later than 15 days before the suspension of operations begins;

(6) provide written notification to HHSC [~~DADS~~] no later than 15 days before the suspension of operations begins;

(7) post a notice, in a location visible outside of the center, for the duration of the suspension that provides information about the suspension of operations, including:

(A) the start and estimated end date of the suspension; and

(B) how to obtain a minor's records during the suspension;

(9) notify HHSC [~~DADS~~] in writing within seven days after resuming normal business operations.

(e) If the center must close with less than 15 days advance notice, the center must follow the requirements in §550.209 [~~§15.209~~] of this division (relating to Emergency Preparedness Planning and Implementation).

§550.203.Financial Solvency and Business Records.

(a) A center must have the financial ability to carry out its functions.

(b) A center must make available to HHSC [~~DADS~~], upon request, business records relating to its ability to carry out its functions. HHSC [~~DADS~~] may conduct a more extensive review of the records if there is a question relating to the accuracy of the records or the center's financial ability to carry out its functions.

(c) A center must maintain business records in their original state. Each entry must be accurate and include the date of entry. Correction fluid or tape may not be used in the record. Corrections must be made in accordance with standard accounting practices.

§550.205.Safety Provisions.

(a) A center must ensure that the local fire marshal's office or the state fire marshal inspects the center annually. The center must keep a copy of the annual fire inspection report on file at the center for two years after the date of inspection.

(b) A center must prepare a fire drill plan and conduct a fire drill at least once every month.

(1) The center's administrator and nursing director must participate in the monthly fire drill.

(2) The center must conduct fire drills at various times of the day.

(3) The center must document a drill on the HHSC [~~DADS~~] Fire Drill Report Form.

(1) review the center's fire drill plan;

(2) evaluate the effectiveness of the plan after each fire drill;

(3) review any problems that occurred during each drill and take corrective action, if necessary; and

(4) maintain documentation to support the requirements of this subsection.

(d) A center must have a working telephone available at all times at the center. Coin operated telephones or cellular telephones are not acceptable for this purpose. If the center has multiple buildings, a working telephone must be located in each of the buildings.

(e) A center must post at or near the immediate vicinity of all telephones:

(1) emergency telephone numbers including:

(A) the HHSC [~~DADS~~] abuse, neglect, and exploitation hotline;

(B) poison control;

(C) 911 or the local fire department, ambulance, and police in communities where a 911 management system is unavailable; and

(D) an emergency medical facility; and

(2) the center's address.

(f) A center must adopt and enforce written policies and procedures for a minor's medical emergency. The policy must include:

(1) a requirement that each minor has an emergency plan, developed in collaboration with a minor's parent, that:

(A) includes instructions from a minor's prescribing physician, as applicable;

(B) includes coordination with other health care providers, including hospice; and

(2) a requirement that staff receive training for medical emergencies;

(3) a requirement that staff receive training in the use of emergency equipment; and

(4) procedures that staff follow when a minor's parent cannot be contacted in an emergency.

(g) If a minor must be transported to an emergency medical facility while at the center, the staff must immediately notify a minor's parent and hospice provider, if applicable. If a parent cannot be contacted, the center must ensure that an individual authorized by the parent or center staff meets a minor at the emergency facility.

(h) The center must prepare a medical emergency transfer form to give to the emergency transportation provider when transporting a minor to an emergency medical facility. The transfer form must include:

(1) the minor's name and age;

(2) the minor's diagnoses, allergies, and medication;

(3) the minor's parent name and contact information;

(4) the minor's prescribing physician name and contact information;

(5) the center's name and contact information; and

(6) the name of the administrator or nursing director.

(i) A center must maintain a first aid kit with unexpired supplies and an automated external defibrillator for minors served at the center that is easily accessible but not within reach of minors.

(j) A center must adopt and enforce written policies and procedures for the verification and monitoring of visitors, including service providers at a center. The policies and procedures must include:

(1) verification of a visitor's identity;

(2) verification of a visitor's authorization to enter a center;

(3) the recording of a visitor's name, organization, purpose of the visit, and the date and time a visitor entered and exited a center;

(4) the center's awareness of a visitor while in a center; and

(5) documentation of the requirements in this subsection.

(k) A center must adopt and enforce written policies and procedures for the release of a minor. The policy must include:

(1) procedures to verify the identity of a person authorized to pick up a minor from the center; and

(2) procedures for the release of a minor when transported by the center in accordance with Subchapter D of this chapter (relating to Transportation).

(l) A center must adopt and enforce written policies and procedures to ensure that no minor is left unattended at the center. The policy must include procedures for:

(1) a minor who arrives at the center;

(2) a minor who remains at the center during operating hours;

(3) a minor who leaves the center; and

(4) staff to conduct daily visual checks at the center at the close of business.

(m) A center must maintain daily records and documentation of the visual check at the end of each day to ensure no minor is left at the center. The documentation must include:

(1) the date and time; and

(2) the signature of the staff member conducting the daily visual checks at the center at the close of business.

(n) Except as otherwise provided in this section, a center must meet the provisions applicable to the health care occupancy chapters of the 2000 edition of the LSC of the National Fire Protection Association (NFPA) and the requirements in Subchapter E of this chapter (relating to Building Requirements). Roller latches are prohibited on corridor doors.

(o) Notwithstanding any provisions of the 2000 edition of the Life Safety Code, NFPA 101, to the contrary, a center may place alcohol-based hand-rub dispensers at the center if:

(1) use of alcohol-based hand-rub dispensers does not conflict with any state or local codes that prohibit or otherwise restrict the placement of such dispensers in health care facilities;

(2) the dispensers are installed in a manner that minimizes leaks and spills that could lead to falls;

(3) the dispensers are installed in a manner or location out of reach of a minor; and

(4) the dispensers are installed in accordance with Chapter 18.3.2.7 or Chapter 19.3.2.7 of the 2000 edition of the LSC, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, 2004.

(p) A center's environment must be free of health and safety hazards to reduce risks to minors. The center must:

(1) use childproof electrical outlets or childproof covers on unused electrical outlets in all rooms to which minors have access at the center;

(2) use safety precautions for strings and cords, including those used on window coverings, and keep them out of the reach of minors;

(3) use safety precautions for all furnishings including cabinets, shelves, and other furniture items that are not permanently attached to the center; and

(4) use play material and equipment that is safe and free from sharp or rough edges and toxic paints.

(q) A center must adopt and enforce a written policy describing whether a center is a weapons-free location. A center must:

(1) provide a copy of the policy to staff, individuals providing services on behalf of a center, an adult minor, and a minor's parent; and

(2) provide a copy of the policy to any person who requests it.

(r) If a center is weapons-free, a center must post a visible and readable sign at the entrance of the center indicating the center is a weapons-free location.

(s) A center must adopt and enforce a written policy prohibiting the use of tobacco in any form, the use of alcohol, and the possession of illegal substances and potentially toxic substances at a center.

§550.206.Person-Centered Direction and Guidance.

(a) A center must adopt and enforce written policies and procedures for the use of person-centered direction and guidance by individuals providing services to minors at the center. The policy must include:

(1) the implementation of a system-wide, person-centered direction and guidance program for minors that includes:

(A) the teaching of successful behavior and coping skills;

(B) proactive strategies to identify and manage a minor's behaviors before they escalate; and

(C) the monitoring and evaluation of the effectiveness of direction and guidance used with a minor by a committee as described in this section;

(2) procedures for ensuring consistent language, practices, and application of direction and guidance by individuals providing services at a center; and

(3) procedures for documenting and providing to a minor's parent a daily report of the minor's behavior.

(b) A center must ensure that only person-centered strategies and techniques that encourage self-esteem, self-control, and self-direction are used for the purposes of direction and guidance of a minor at a center. A center must not use a restraint as part of person-centered direction and guidance.

(1) individualized and consistent for each minor;

(2) differentiated in both nature and intensity based on a minor's level of behavior;

(3) appropriate to the minor's level of understanding and functional or educational development; and

(4) directed toward teaching the minor successful behavior, awareness of behavior triggers and self-control, including:

(A) encouraging a minor to develop positive behavior in accordance with a minor's individualized psychosocial program;

(B) redirecting behavior using positive statements; and

(d) A center must ensure that quiet time, if used, is:

(1) in accordance with the minor's psychosocial program and plan of care;

(2) brief and under continuous face-to-face observation by center staff;

(3) appropriate for the minor's age and development;

(4) limited to no more than one minute per year of the minor's developmental age; and

(5) does not place a minor alone in a room.

(e) A center must ensure the protection of minors at the center from harsh, cruel, or unusual treatment. Negative discipline is considered punishment and abuse and is prohibited at a center, including:

(1) corporal punishment or threats of corporal punishment;

(2) punishment associated with food, naps, or toilet training;

(3) pinching, shaking, or biting a minor;

(4) hitting a minor with a hand or object;

(5) putting anything in or on a minor's mouth;

(6) humiliating, ridiculing, rejecting, or yelling at a minor;

(7) subjecting a minor to harsh, abusive, or profane language;

(8) placing a minor alone in a locked or darkened room, bathroom, or closet without windows; and

(9) requiring a minor to remain silent or inactive for inappropriately long periods of time for the minor's developmental age.

(f) The center must establish a person-centered direction and guidance committee to review the techniques and strategies used at a center to:

(1) determine whether the individualized direction and guidance used as established in a plan of care is consistently applied for each minor in accordance with center policy; and

(2) evaluate the frequency and outcomes of strategies and techniques used with a minor to:

(A) determine the impact of the direction and guidance on a minor's ability to achieve progress in goals;

(B) determine effectiveness of the minor's program; and

(C) recommend the use of new strategies and techniques when current strategies and techniques are determined to be ineffective.

(g) The committee must include:

(1) the center's administrator;

(2) the center's nursing director or designee;

(3) an individual providing psychosocial treatment and services on behalf of a center; and

(4) a parent or an individual from a parent council or support group for minors receiving services at the center.

(h) The center is not required to include a parent or individual from a parent council or support group if, after a good faith effort, the center is unable to include a parent or individual in a committee meeting. The center must document, for review by HHSC [~~DADS review~~], a good faith effort to include a parent or individual from a parent council or support group at each meeting.

(i) The center must adopt and enforce written policies and procedures for the frequency, format, and documentation of committee meetings.

(j) A center must provide its written person-centered direction and guidance policy to all parents, employees, volunteers, and contractors. The center must maintain documentation of acknowledgment of the written policy from all employees, volunteers, and contractors.

§550.207.Protective Devices and Restraints.

(a) Protective Devices. A center must ensure that a protective device is used only as ordered by a minor's prescribing physician, as agreed to by an adult minor or a minor's parent, and in accordance with the minor's plan of care.

(1) A center may use a protective device only in the following circumstances:

(A) as part of a therapeutic regimen of basic services for a minor's physical health and development;

(B) during medical, nursing, diagnostic, and dental procedures as prescribed by a physician's order and to protect the health and safety of a minor; or

(2) A center must adopt and enforce written policies and procedures requiring a protective device to be used as described in this subsection and in accordance with a minor's plan of care.

(3) A center must not implement a physician's order for the use of a protective device on a pro re nata (PRN) or as-needed basis.

(4) A center must ensure a physician's order is obtained before using a protective device at the center. The physician's order must include:

(A) the circumstances under which a protective device may be used at the center;

(B) instructions on how long a protective device may be used at the center; and

(C) any individualized, less restrictive interventions described in the minor's plan of care that must be used before using a protective device.

(5) A center must ensure that in implementing a physician's order for a protective device that an RN, with input from an adult minor, a minor's parent, and the IDT:

(A) conducts an assessment of a minor's current and ongoing need for a protective device at a center;

(B) reviews the physician's order for a protective device, as described in paragraph (4) of this subsection; and

(C) obtains and documents in a minor's medical record the written consent of an adult minor or a minor's parent to use a protective device at the center.

(6) Before using a protective device for the first time with a minor, the center must ensure an RN provides oral and written notification to the adult minor or the minor's parent of the right at any time to withdraw consent and discontinue use of a protective device at the center.

(7) The center must ensure that a staff member who will apply a protective device has been properly trained in the use of a protective device, as ordered in the minor's plan of care, in accordance with this subsection, and in accordance with §550.415(b)(8)(F) [~~§15.415(b)(8)(F)~~] of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training).

(8) If a protective device is used for a minor, the center must ensure:

(A) the minor is assessed by an RN, in accordance with the physician's order but no less than once every hour to determine if the protective device must be repositioned or discontinued;

(B) except for sedation, the protective device is removed to conduct the RN assessment described in subparagraph (A) of this paragraph and removed more frequently as determined necessary by the RN's assessment;

(C) center staff replaces the protective device, if necessary, after the assessment, in accordance with the physician's order;

(D) a minor's physician is notified immediately if an assessment determines a change in the minor's condition or a negative reaction to the protective device has occurred, including notification of:

(i) the minor's psychosocial condition;

(ii) the minor's reaction to the protective device;

(iii) the minor's medical condition; and

(iv) the need to continue or discontinue the use of the protective device;

(E) the type and frequency of use of the protective device is documented in the minor's medical record;

(F) the effects of a protective device on the minor's health and welfare are evaluated and documented in the medical record; and

(G) an RN, an adult minor, a minor's parent, and the IDT, at least every 180 days, or as the minor's needs change, review, with input and direction from the minor's prescribing physician, the use of a protective device to determine its effectiveness and the need to continue the use of the protective device.

(b) Restraints. A center may use a restraint only in a behavioral emergency when the immediate health and safety of the minor or another minor are at risk. A center must not use a chemical or mechanical restraint. [~~A center may use only the following restraints:~~]

(1) The center must adopt and enforce a written policy and procedures regarding the use of restraints in a behavioral emergency, including whether a center is a restraint-free environment.

(2) A center must ensure that the use of a restraint at a center must not be in a manner that:

(A) obstructs a minor's airway, including the placement of anything in, on, or over the minor's mouth or nose;

(B) impairs the minor's breathing by putting pressure on the minor's torso;

(D) extends muscle groups away from each other;

(E) uses hyperextension of joints; or

(F) uses pressure points or pain.

(3) A center must ensure that a restraint is not used for:

(A) controlling a minor's behavior in a non-emergency;

(B) negative discipline as described in §550.206 [~~§15.206~~] of this division (relating to Person-Centered Direction and Guidance);

(D) coercion or retaliation; or

(E) as part of a behavior component of a minor's psychosocial program.

(4) A center must not implement a physician's order for the use of a restraint on a pro re nata (PRN) or as-needed basis.

(5) A center must ensure that a staff member whose job responsibilities will include the use or application of a restraint during a behavioral emergency has been properly trained in the use of a restraint for minors served at the center, in accordance with this section, and in accordance with §550.415(b)(8)(G) [~~§15.415(b)(8)(G)~~] of this subchapter [~~(relating to Staffing Policies for Staff Orientation, Development, and Training)~~].

(6) If a center restrains a minor due to a behavioral emergency, the center must ensure:

(A) all less restrictive options available are exhausted before using a restraint;

(B) the restraint is limited to the use of such reasonable force as is necessary to address the emergency;

(C) the restraint is discontinued immediately at the point when the emergency no longer exists but no more than 15 minutes after the restraint was initiated;

(D) the restraint is implemented in such a way as to protect the health and safety of the minor and others;

(E) immediately after the restraint is discontinued, the minor is assessed by an RN;

(F) immediately following an RN assessment, medical attention is provided for the minor if determined necessary by the RN assessment;

(G) within three days after the use of the restraint, an assessment is conducted by an RN as described in §550.504 [~~§15.504~~] of this subchapter [~~chapter~~] (relating to Psychosocial Treatment and Services) to determine if the development and implementation of a psychosocial treatment and services program is needed for the minor to address the minor's behavior and reduce the occurrence of future behavioral emergencies; and

(H) within three days after the use of the restraint, an RN reviews and updates a minor's plan of care and psychosocial treatment and services program as determined appropriate.

(7) If a center restrains a minor due to a behavioral emergency, the center must ensure the following documentation and notifications occur:

(A) immediately after the restraint is discontinued, information about the restraint is documented, including:

(i) the name of the individual who administered the restraint;

(ii) the date and time the restraint began and ended;

(iii) the location of the restraint;

(iv) the nature of the restraint;

(v) a description of the setting and activity in which the minor was engaged immediately preceding the use of the restraint;

(vi) the behavior that prompted the restraint;

(vii) the efforts made to de-escalate the situation and the less restrictive alternatives attempted before the restraint; and

(viii) the minor's condition after the restraint was discontinued;

(B) within 24 hours after the use of the restraint, written documentation regarding the use of the restraint and the RN assessment conducted immediately after the use of the restraint is included in a minor's medical record;

(C) documentation of nursing director and administrator oral and written notifications as described in subparagraphs (E) and (I) of this paragraph, including nursing director and administrator signatures acknowledging receipt of notifications must be included in the minor's medical record;

(D) documentation of parent oral and written notifications as described in subparagraphs (F) and (J) of this paragraph, including a parent signature acknowledging receipt of notifications must be included in the minor's medical record;

(E) immediately after the restraint is used, the administrator and director of nursing are notified orally that the restraint occurred;

(F) on the day the restraint is used, the minor's parent is notified orally that the restraint occurred;

(G) on the day the restraint is used, the center's staff responsible for psychosocial treatment and services is notified orally that the restraint occurred;

(H) immediately after the RN assessment is conducted in accordance with paragraph (6)(E) of this subsection, if the assessment determines a change in the minor's condition or a negative reaction to the restraint has occurred, the minor's physician is notified of the restraint and the minor's condition, including:

(i) the minor's medical condition;

(ii) the minor's reaction to the restraint; and

(iii) the minor's psychosocial condition;

(I) within one hour after the use of the restraint, the administrator and director of nursing are notified in writing of the restraint, including the information in subparagraph (A) of this paragraph; and

(J) within one day after the use of the restraint, the minor's parent is notified in writing, in a language and format the parent understands, of the restraint, including the information in subparagraph (A) of this paragraph. [;]

(8) The IDT must review, on an annual basis or more frequently as needed, all behavioral emergencies that occurred at the center during the time period being reviewed to determine the appropriateness of the center's response and to identify strategies for reducing behavioral emergencies at the center.

(9) A center must maintain documentation of compliance with this section.

§550.210.Sanitation, Housekeeping, and Linens.

(a) A center must ensure a sanitary environment by following accepted standards of practice and maintain a safe physical environment free of hazards for minors, staff, and visitors.

(b) A center must ensure that the following conditions are met.

(1) Wastewater and sewage must be discharged into a state-approved municipal sewage system. An on-site sewage facility must be approved by the Texas Commission on Environmental Quality (TCEQ) or authorized agent.

(2) The water supply must be from a system approved by the Public Drinking Water Section of the TCEQ, or from a system regulated by an entity responsible for water quality in the jurisdiction where the center is located as approved by the Public Drinking Water Section of the TCEQ.

(3) Waste, trash, and garbage must be disposed of from the premises at regular intervals in accordance with state and local practices. Excessive accumulations are not permitted. Outside containers must have tight-fitting lids left in closed position. Containers must be maintained in a clean and serviceable condition.

(4) Center grounds must be well kept and the exterior of the building, including sidewalks, steps, porches, ramps, and fences, must be in good repair.

(5) The interior of the center's buildings including walls, ceilings, floors, windows, window coverings, doors, plumbing, and electrical fixtures must be in good repair.

(6) Pest control must be provided by a licensed structural pest control applicator with a license category for pests. The center must maintain documented evidence of routine efforts to remove rodents and insects.

(7) The center must be kept free of offensive odors, accumulations of dirt, rubbish, dust, and hazards. Storage areas, attics, and cellars must be free of refuse and extraneous materials.

(c) A center must adopt and enforce a written work plan for housekeeping operations, with categorization of cleaning assignments as daily, weekly, monthly, or annually within each area of the center.

(d) A center must ensure the provision of housekeeping and maintenance of the interior, exterior, and grounds of the center in a safe, clean, orderly, and attractive manner. The center must provide housekeeping and maintenance staff with equipment and supplies if needed. A center must designate staff to be responsible for overseeing the housekeeping services.

(e) A center must develop procedures for the selection, use, and disposal of housekeeping and cleaning products and equipment. The center must ensure:

(1) the use of Environmental Protection Agency-approved [~~EPA approved~~] cleaning products appropriate for the application and materials to be sanitized;

(2) the following of manufacturer instructions for use and disposal of cleaning products;

(3) all bleaches, detergents, disinfectants, insecticides, and other poisonous substances are kept in a safe place accessible only to staff; and

(4) all products are labeled.

(f) A center must ensure a sufficient supply of clean linens is available to meet the needs of minors. Clean laundry must be provided in-house by the center, through a contract with another health care center, or with an outside commercial laundry service.

(g) A center must ensure:

(1) linens are handled, stored, and processed so as to control the spread of infection;

(2) linens are maintained in good repair;

(3) linens are washed, dried, stored, and transported in a manner which will produce hygienically clean linen;

(4) the washing process has a mechanism for removing soil and killing bacteria;

(5) clean linens are stored in a clean linen area easily accessible to the staff;

(6) soiled linens and clothing are stored separately from clean linen and clothing;

(7) soiled linens and clothing are stored in well-ventilated areas, and are not permitted to accumulate at the center;

(8) soiled linens and clothing are transported in accordance with procedures consistent with universal precautions;

(9) soiled linens are not sorted, laundered, rinsed, or stored in bathrooms, corridors, food preparation area, or food storage areas;

(10) a minor's clothing stored at the center is cleaned after each use; and

(11) staff wash their hands both after handling soiled linen and before handling clean linen.

§550.211.Infection Prevention and Control Program and Vaccinations Requirements.

(a) A center must establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment by preventing the development and transmission of disease and infection. Under the IPCP, the center must:

(1) investigate, prevent, and control infections at the center;

(2) decide what procedures, such as isolation, should be applied to an individual minor;

(3) address vaccine preventable diseases in accordance with THSC, Chapter 224;

(4) address hepatitis B vaccinations in accordance with Occupational Safety and Health Administration;

(5) address tuberculosis requirements; and

(6) maintain a record of incidents and corrective actions relating to infections.

(b) A center must provide IPCP information to employees, contractors, volunteers, parents, health care providers, other service providers, and visitors.

(c) A center's IPCP must include written policies and procedures for admissions and attendance of minors who are at risk for infections or present a significant risk to other minors. The policy must include that a minor is accepted only:

(1) as authorized by a minor's prescribing physician:

(2) as determined by the center's medical director's assessment of the risk;

(3) as determined by the medical and nursing director review, on a case-by-case basis, to determine appropriateness of admission to or attendance at the center; and

(4) in accordance with Centers for Disease Control (CDC) guidelines.

(d) The center's IPCP must include written policies and procedures for preventing the spread of infection.

(1) If the center determines, in accordance with its IPCP, that a minor must be isolated to prevent the spread of infection, the center must isolate a minor.

(A) The center must maintain an isolation room with a glass window for observation of a minor. The isolation room must be equipped with emergency outlets and equipment as necessary to provide care to a minor. The isolation room must have a dedicated bathroom not accessible to the center's other rooms if appropriate to control the spread of infectious disease.

(B) The center must ensure that all equipment is thoroughly cleaned and disinfected before being placed in the isolation room and before being removed from the room.

(i) notification to a minor's parent of the minor's condition and the center's recommendation of isolation or removal based on the minor's risk assessment;

(ii) the arrangement of transportation if the minor must be removed from the center; and

(iii) the return of a minor to the center, as determined by a reassessment conducted by a nurse that the minor no longer poses a risk to other minors.

(2) The center must prohibit employees, volunteers, and contractors with an infectious disease or infected skin lesions from direct contact with minors or food, if direct contact will transmit the disease.

(3) The center's infection control policy must provide that staff, volunteers, and contractors wash their hands between each treatment and care interaction with a minor.

(4) The center must immediately report the name of any minor with a reportable disease as specified in 25 Texas Administrative Code [~~TAC~~] Chapter 97, Subchapter A (relating to Control of Communicable Diseases) to the city health officer, county health officer, or health unit director having jurisdiction, and implement appropriate infection control procedures as directed by the local health authority or the Texas Department of State Health Services.

(e) The center must assign a crib, bed, or sleep mat for a minor's exclusive use each day. A center must label cribs, beds, and sleep mats with the minor's name.

(f) A center must place liquid soap, disposable paper towels, and trash containers at each sink.

(g) The center must adopt and enforce written policies and procedures for the control of communicable diseases for employees, contractors, volunteers, parents, health care providers, other service providers, and visitors and must maintain evidence of compliance.

(h) The center must adopt and enforce written policies and procedures for the control of an identified public health disaster.

(1) If a center determines or suspects that an employee, volunteer, or contractor providing services has been exposed to, or has a positive screening for, a communicable disease, the center must respond according to current CDC guidelines and keep documentation of the action taken.

(2) If the center determines that an employee, volunteer, or contractor providing services has been exposed to a communicable disease, the center must conduct and document a reassessment of the risk classification. The center must conduct and document subsequent screenings based upon the reassessed risk classification.

(3) If the center determines that an employee, volunteer, or a contractor providing services at the center is suspected of having a communicable disease, the individual must not return to the center until the individual no longer poses a risk of transmission as documented by a written physician's statement.

(i) The center must conduct and document an annual review that assesses the center's current risk classification according to the current CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Settings and 25 Texas Administrative Code [~~TAC~~] Chapter 97, Subchapter A.

(1) The center must have a system in place to screen all individuals providing services at the center.

(2) The center must require employees, volunteers, and contractors providing services to provide evidence of current tuberculosis screening before providing services at the center. The center must maintain evidence of compliance.

(3) Any employee, volunteer, or contractor providing services at a center with positive results must be referred to the person's personal physician, and if active tuberculosis is suspected or diagnosed, the person must be excluded from work until the physician provides written approval to return to work.

(j) A center must adopt and enforce written policies and procedures to protect a minor from vaccine preventable diseases, in accordance with THSC[,] Chapter 224.

(1) The policy must:

(A) require an employee, volunteer, or contractor providing direct care to receive vaccines for the vaccine preventable diseases specified by the center based on the level of risk the employee, volunteer, or contractor, presents to minors by the employee's, volunteer's, or contractor's routine and direct exposure to minors;

(B) specify the vaccines an employee, volunteer, or contractor who provides direct care is required to receive in accordance with subsection (i) of this section;

(C) include procedures for the center to verify that an employee, volunteer, or contractor who provides direct care has complied with the policy;

(D) include procedures for the center to exempt an employee, volunteer, or contractor who provides direct care from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC;

(E) include procedures, including using protective equipment such as gloves and masks, to protect minors from exposure to vaccine preventable diseases, based on the level of risk the employee, volunteer, or contractor presents to minors by the employee's, volunteer's, or contractor's routine and direct exposure to minors;

(F) prohibit discrimination or retaliatory action against an employee, volunteer, or contractor who provides direct care and who is exempt from the required vaccines for the medical conditions identified as contraindications or precautions by the CDC, except that required use of protective medical equipment, such as gloves and masks, will not be considered retaliatory action;

(G) require the center to maintain a written or electronic record of each employee's, volunteer's, or contractor's compliance with or exemption from the policy; and

(H) include disciplinary actions the center may take against an employee, volunteer, or contractor providing direct care who fails to comply with the policy.

(2) The center must have a written policy describing whether it will exempt an employee, volunteer, or contractor providing direct care:

(A) from the required vaccines based on reasons of conscience, including a religious belief; and

(B) prohibit an employee, volunteer, or contractor providing direct care who is exempt from the required vaccines from having contact with minors during a public health disaster.

(k) The center must adopt and enforce written policies and procedures to identify employees, volunteers, or contractors at risk of directly contacting blood or other potentially infectious materials in accordance with the Occupational Safety and Health Standards in [~~Administration (OSHA),~~] 29 Code of Federal Regulations §1910.1030 [~~Part 1910.1030 and Appendix A~~] relating to Bloodborne pathogens [~~Pathogens~~].

(l) A center must ensure that its employees, volunteers, and contractors comply with:

(1) the center's IPCP;

(2) the Communicable Disease Prevention and Control Act, THSC Chapter 81; and

(3) THSC Chapter 85, Subchapter I, concerning the prevention of the transmission of human immunodeficiency virus and hepatitis B virus.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402396

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 2. ADMINISTRATION AND MANAGEMENT

26 TAC §§550.301, 550.303 - 550.306, 550.308 - 550.311

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.301.License Holder's Responsibilities.

(a) The license holder is responsible for the conduct of the center and for the adoption, implementation, and enforcement of the written policies required throughout this chapter. The license holder is also responsible for ensuring that these policies comply with THSC Chapter 248A and the applicable provisions of this chapter and are administered to provide safe, professional, and quality health care.

(b) The persons described in §550.101(f) [~~§15.101(f)~~] of this chapter (relating to Criteria and Eligibility for a License) must not have been convicted of an offense described in §560.2 [~~§99.2~~] of this title (relating to Convictions Barring Licensure), during the time frames described in that chapter.

(c) The license holder must ensure that all documents submitted to HHSC [~~DADS~~] or maintained by the center as required by this chapter are accurate and do not misrepresent or conceal a material fact.

(d) The license holder must comply with an order of the executive [~~DADS~~] commissioner or other enforcement orders that may be imposed on the center in accordance with THSC Chapter 248A and this chapter.

(e) The license holder of the center must have full legal authority and responsibility for the operation of the center.

(f) A license holder must designate in writing an individual who meets the qualifications and conditions set out in §550.303 [~~§15.303~~] of this division [~~subchapter~~ ] (relating to Administrator and Alternate Administrator Qualifications and Conditions) to serve as the administrator of the center.

(g) A license holder must designate in writing an alternate administrator who meets the qualifications and conditions of an administrator set out in §550.303 [~~§15.303~~] of this division [~~subchapter~~] to act in the absence of the administrator or when the administrator is unavailable to the staff during the center's operating hours.

(h) A license holder must ensure the position and designation of an administrator or alternate administrator is filled with a qualified staff.

(i) A license holder must ensure maintenance of documentation of efforts to ensure a vacancy in the position of an administrator or alternate administrator does not last more than 30 days.

(j) A license holder must ensure all written notices to HHSC [~~DADS~~] required by this chapter, unless otherwise specified in this chapter, are submitted through the online portal [~~as described in the instructions provided on the DADS website~~].

§550.303.Administrator and Alternate Administrator Qualifications and Conditions.

(a) The administrator and alternate administrator of a center must have two years of experience in supervision and management in a pediatric health care setting and meet one of the following criteria:

(1) be a physician licensed in Texas to practice medicine in accordance with Texas Occupations Code, Chapter 155;

(2) be an RN with a master's or baccalaureate degree in nursing and be licensed under the Nursing Practice Act, Texas Occupations Code, Chapter 301, with no disciplinary actions;

(3) be a college graduate with a bachelor's degree with one additional year of supervision or management experience in a health care setting;

(4) have an associate [~~associate's~~] degree in health care or administration with two additional years of supervision or management experience in a health care setting; or

(5) have an associate [~~associate's~~] degree in nursing and currently licensed under the Nursing Practice Act, Texas Occupations Code, Chapter 301, with no disciplinary action with two additional years of supervision or management experience in a health care setting.

(b) The administrator and the alternate administrator of a center must be at least 25 years of age.

(c) An administrator and alternate administrator of a center must meet the initial training requirements specified in §550.305 [~~§15.305~~] of this division (relating to Initial Training in Administration) and the continuing training requirements specified in §550.306 [~~§15.306~~] of this division (relating to Continuing Training in Administration).

(d) A person is not eligible to be the administrator or alternate administrator of a center if the person was the administrator of a center cited with a violation that resulted in HHSC [~~DADS~~] taking enforcement action against the center while the person was the administrator of the cited center.

(1) This subsection applies for 12 months after the date of the enforcement action.

(2) For purposes of this subsection, enforcement action means license suspension, licensure revocation, emergency suspension of a license, denial of an application for a license, or the issuance of an injunction. Enforcement action does not include administrative or civil penalties.

(e) An administrator or alternate administrator must not be convicted of an offense described in §560.2 [~~§99.2~~] of this title (relating to Convictions Barring Licensure) during the time frames described in that chapter.

(f) The designated administrator and alternate administrator of a center must be full-time employees of the center.

(g) The designated administrator or alternate administrator may serve as the nursing director or alternate nursing director if the administrator or alternate administrator meets the nursing director qualifications as described in §550.309 [~~§15.309~~ ] of this division (relating to Nursing Director and Alternate Nursing Director Qualifications and Conditions).

(h) The designated administrator or alternate administrator may be included in the center's staffing ratio if:

(1) the administrator or alternate administrator is a licensed nurse or meets the qualifications in §550.409 [~~§15.409~~] of this subchapter (relating to Direct Care Staff Qualifications); and

(2) the center's actual census is less than four minors.

(i) The designated administrator or alternate administrator must not be included in the center's staffing ratios when functioning as the nursing director or alternate nursing director.

(j) The designated administrator must manage only one center.

§550.304.Administrator Responsibilities.

(a) An administrator of a center must be responsible for implementing and supervising the administrative policies and operations of the center and for administratively supervising the provision of all services to minors on a day-to-day basis.

(b) A center's administrator must:

(1) ensure that the center complies with applicable federal, state, and local laws, rules, and regulations;

(2) manage the daily operations of the center;

(3) organize and direct the center's ongoing functions;

(4) ensure the availability of qualified staff and ancillary services to ensure the health, safety, and proper care of each minor;

(5) ensure criminal history [~~checks~~], employee misconduct registry, [~~and~~] nurse aide registry, and medication aide registry checks are conducted for required staff before employment;

(6) ensure the implementation of the center's training program policies and procedures;

(7) familiarize staff with regulatory issues, as well as the center's policies and procedures;

(8) ensure that the documentation of services provided is accurate and timely;

(9) manage census records, including daily, actual, and total, in accordance with §550.803 [~~§15.803~~ ] of this chapter (relating to Census);

(10) ensure that the center immediately notifies a minor's parent of any and all accidents or unusual incidents involving their minor or that had the potential to cause injury or harm to a minor;

(11) ensure that the center provides written notice to the parent of accidents or unusual incidents involving their minor on the day of occurrence;

(12) maintain a record of accidents or unusual incidents involving a minor or staff member that caused, or had the potential to cause, injury or harm to a person or property at the center;

(13) maintain a copy of current contractor agreements with third party providers contracted by the center;

(14) maintain a copy of current written agreements with each contractor;

(15) ensure adequate staff education and evaluations according to requirements in §550.415 [~~§15.415~~] of this subchapter (relating to Staffing Policies for Staff Orientation, Development, and Training);

(16) maintain documented development programs for all staff;

(17) ensure the accuracy of public information materials and activities made available and presented on behalf of the center;

(18) ensure implementation of an effective budgeting and accounting system consistent with good business practice that promotes the health and safety of the center's minors; and

(19) supervise the annual distribution and evaluation of the responses to the parent-satisfaction surveys on all minors served.

§550.305.Initial Training in Administration.

(a) This section applies to an administrator and alternate administrator designated as an administrator or alternate administrator of a center.

(b) Before designation, an administrator or alternate administrator must complete the HHSC [~~DADS~~] pre-licensing program training titled Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas.

(c) An administrator and alternate administrator of a center must complete a total of 12 clock hours of training in the administration of a center before the end of the first 12 months after designation to the position.

(d) The initial 12 clock hours of training must address:

(1) information on state and federal laws applicable to a center, including:

(A) the Americans with Disabilities Act;

(B) the Civil Rights Act of 1991;

(D) the Family and Medical Leave Act of 1993;

(E) Public Law 111-148 Patient Protection and Affordable Care Act; and

(F) Occupational Safety and Health Administration requirements; and [.]

(2) information regarding the prevention, detection and reporting of fraud, waste, and abuse;

(3) legal issues regarding advance directives;

(4) infection control;

(5) communicable disease reporting;

(6) nutrition;

(7) principles of person-centered direction and guidance; and

(8) provision of services to a minor.

(e) The 12-clock-hour training requirement described in subsection (d) of this section must be met through structured, formalized classes, correspondence courses, competency-based computer courses, training videos, distance learning programs, or off-site training courses. Subject matter that deals with the internal affairs of a center does not qualify for clock hours.

(1) The training must be provided or produced by:

(A) an academic institution;

(B) a recognized state or national organization or association;

(D) an accredited pediatric hospital; or

(E) HHSC [~~DADS~~] or other state agency.

(2) If a consultant provides or produces the training, the training must be approved by a recognized state or national organization or association. The center must maintain documentation of this approval or recognition for review by HHSC [~~DADS~~] inspectors.

(3) An administrator and alternate administrator may apply joint training provided by HHSC [~~DADS~~] toward the 12 clock hours of training required by this section if the joint training meets the training requirements described in subsection (d) of this section.

(f) Documentation of administrator and alternate administrator training must:

(1) be on file at the center; and

(2) contain:

(A) the name of the class or workshop;

(B) course content, including the curriculum;

(D) name and contact information of the entity and trainer who provided the training.

(g) An administrator and alternate administrator must not apply the pre-licensing program training as part of the 12 clock hours of training required in this section.

(h) After completing 12 clock hours of initial training during the first 12 months after designation as an administrator and alternate administrator, an administrator and alternate administrator must complete the continuing training requirements as specified in §550.306 [~~§15.306~~] of this division (relating to Continuing Training in Administration) in each subsequent 12-month period after designation.

§550.306.Continuing Training in Administration.

(a) An administrator and alternate administrator must complete 12 clock hours of continuing training within each subsequent 12-month period beginning with the date of designation. The 12 clock hours of continuing training must include at least two of the following topics and may include other topics relating to the duties of an administrator:

(1) any one of the training topics listed in §550.305(d) [~~§15.305(d)~~] of this division (relating to Initial Training in Administration);

(2) development and interpretation of the center policies;

(3) basic principles of management in a licensed health care setting;

(4) ethics;

(5) quality improvement;

(6) risk assessment and management;

(7) financial management;

(8) skills for working with minors, a minor's parent, and other professional service providers;

(9) community resources;

(10) communicable disease reporting; or

(11) marketing.

(b) In addition to the 12 clock hours of training required in this section, an administrator or alternate administrator must complete the Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas provided by HHSC [~~DADS~~] every three years from the date of designation to the position.

(c) The center must keep documentation of administrator and alternate administrator continuing training on file at the center and maintain:

(1) the name of the class or workshop;

(2) course content, including the curriculum;

(3) hours and dates of the training; and

(4) name and contact information of the entity and trainer who provided the training.

(d) An administrator or alternate administrator must not apply the pre-licensing program training toward the continuing training requirements in this section.

§550.308.Medical Director Responsibilities.

The medical director must:

(1) review the services provided at the center to ensure a high quality of services;

(2) maintain a liaison role with the medical community in the location of the center's place of business;

(3) participate in the development and implementation of appropriate performance improvement and safety initiatives as directed by the Quality Assessment and Performance Improvement (QAPI) program;

(4) participate in the development of new programs and modifications of existing programs at the center;

(5) designate a physician as defined in §550.5 [~~§15.5~~] of this chapter (relating to Definitions) to provide medical consultation in the event the medical director is unavailable to the center's staff;

(6) serve on committees as defined and required by this chapter and the center's polices;

(7) consult with the center's administrator and nursing director on the health status of the center's staff as it relates to the center's IPCP and on a minor's health and safety or as threats to infection control arise;

(8) review reports of accidents and unusual incidents occurring at the center and identify to the center's administrator hazards to health and safety as directed by the QAPI program;

(9) participate in the development and implementation of policies and procedures for the delivery of emergency services for minors;

(10) participate in the development and implementation of policies and procedures for the use of restraints; and

(11) participate in the development and implementation of policies and procedures for the delivery of physician's services when a minor's prescribing physician or designated alternate is not available.

§550.309.Nursing Director and Alternate Nursing Director Qualifications and Conditions.

(a) A center must designate a nursing director and alternate nursing director who meet the qualifications and conditions set out in this section and who have completed the HHSC [~~Texas Health and Human Services Commission (HHSC)~~] pre-licensing program training titled ["] Overview of Prescribed Pediatric Extended Care Center Licensing Standards in Texas.["]

(b) The nursing director and alternate nursing director must have the following qualifications:

(1) a valid RN license under Texas Occupations Code, Chapter 301, with no disciplinary action;

(2) a valid certification in Pediatric Cardiopulmonary [~~Cardio Pulmonary~~] Resuscitation or Basic Cardiac Life Support; and

(3) a minimum of two years of supervision and management in employment in a pediatric setting caring for a medically or technologically dependent minor or at least two years of supervision in one of the following specialty settings:

(A) pediatric intensive care;

(B) neonatal intensive care;

(D) center;

(E) home health or hospice agency specializing in pediatric care;

(F) ambulatory surgical center specializing in pediatric care; or

(G) have comparable pediatric unit experience in a hospital for two consecutive years before the person applies for the position of nursing director.

(1) The nursing director must be a full-time employee of the center.

(2) The nursing director or alternate nursing director may serve as the administrator or alternate administrator of the center if the nursing director or alternate nursing director meets the administrator qualifications as described in §550.303 of this division (relating to Administrator and Alternate Administrator Qualifications and Conditions).

(3) A center must designate an alternate nursing director who meets the qualifications as specified in this section who will assume the responsibilities of the nursing director when the nursing director is unavailable during the center's operating hours.

(4) The nursing director must not be included in the center's staffing ratio when the center's actual census is less than four minors and the nursing director is also functioning as the administrator.

(5) The designated alternate nursing director must not be included in the center's staffing ratio when functioning as the nursing director, administrator, or alternate administrator.

§550.310.Nursing Director Responsibilities and Supervision Responsibilities.

The center's nursing director's responsibilities must include, but are not limited to:

(1) supervising all aspects of a minor's plan of care to ensure the minor's plan of care is implemented as ordered;

(2) supervising all activities of the center's professional nursing staff and direct care staff to ensure compliance with current standards of accepted nursing practice;

(3) ensuring compliance with all federal and state laws, rules, and regulations in this chapter;

(4) supervising the daily clinical operations of the center;

(5) ensuring the documentation of the center's actual, daily, and total census in accordance with §550.803 [~~§15.803~~] of this subchapter (relating to Census) and §550.410 [~~§15.410~~] of this subchapter (relating to Nursing Services Staffing Ratio);

(6) ensuring the documentation of the center's staffing ratios in accordance with §559.410 [~~§15.410~~] of this subchapter;

(7) supervising the implementation of staffing policies to ensure that only qualified staff are hired by the center, including verification of licensure and certification before employment and annually thereafter;

(8) ensuring the maintenance of records to support competency of the center's nursing and direct care staff;

(9) ensuring the implementation of the center's policies and procedures that establish and support quality care to a minor;

(10) providing orientation and in-service training to employees and providers of basic services to promote effective basic services and safety to a minor;

(11) performing timely annual performance evaluations for the center's nursing and direct care staff;

(12) ensuring participation in regularly scheduled continuing training for the center's nursing and direct care staff; and

(13) ensuring that the care at the center promotes effective services and the safety of a minor.

§550.311.Prohibition of Solicitation.

(a) A center must adopt and enforce a written policy to ensure compliance of the center and its employees, volunteers, and contractors with Texas Occupations Code, Chapter 102.

(b) HHSC [~~DADS~~] may take enforcement action against a center in accordance with Subchapter G of this chapter (relating to Enforcement) if the center violates Texas Occupations Code, §102.001 or §102.006.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402397

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 3. NURSING AND STAFFING REQUIREMENTS

26 TAC §§550.402 - 550.406, 550.409 - 550.411, 550.413, 550.415, 550.417, 550.418

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.402.Registered Nurse Qualifications.

(a) An [A] RN providing services on behalf of a center must have at least the following qualifications and experience:

(1) a valid RN license under Texas Occupations Code, Chapter 301, with no disciplinary action;

(2) valid certifications in Pediatric Cardiopulmonary [~~Cardio Pulmonary~~] Resuscitation and Basic First Aid; and

(3) one of the following:

(A) one year of pediatric specialty experience with emphasis on medically and technologically dependent minors, obtained within the previous five years; or

(B) sufficient skills to meet the competency and training requirements described in subsection (b) of this section.

(b) A center must adopt and enforce a written policy regarding an RN who qualifies to provide services at the center under subsection (a)(3)(B) of this section. The policy must:

(1) require an RN qualified under subsection (a)(3)(B) of this section to complete a training program that is determined appropriate by the Director of Nursing and conducted by an RN on the RN responsibilities described in §550.403 [~~§15.403~~ ] of this division (relating to Registered Nurse Responsibilities) and that includes hands-on training;

(2) require, before performing the RN responsibilities described in §550.403 [~~§15.403~~] of this division, an RN qualified under subsection (a)(3)(B) of this section to demonstrate competency in performing the responsibilities described in §550.403 [~~§15.403~~] of this division, as determined by an RN;

(3) describe procedures for increased supervision of an RN qualified under subsection (a)(3)(B) of this section during the training program, competency evaluation, and for three months after completion of the competency evaluation to ensure the health and safety of minors; and

(4) prohibit an RN qualified under subsection (a)(3)(B) of this section from performing the responsibilities in §550.403 [~~§15.403~~] of this division or being included in the nursing services staffing ratio as an RN, as described in §550.410 [~~§15.410~~] of this division (relating to Nursing Services Staffing Ratio), until the RN completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.

(c) An RN qualified under subsection (a)(3)(B) of this section must meet the requirements in §550.415 [~~§15.415~~ ] of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 [~~§15.416~~] of this division (relating to Staff Development Program).

§550.403.Registered Nurse Responsibilities.

An RN providing services on behalf of a center must be responsible for the following:

(1) maintaining compliance with the standards of nursing practice and delegation;

(2) developing a minor's plan of care;

(3) providing nursing interventions that includes parental training, information, and education to increase a parent's confidence and competence in caring for a minor;

(4) coordinating services with other service providers;

(5) monitoring the ongoing physical and developmental growth of a minor;

(6) having knowledge of access to available community resources;

(7) participating on the IDT and in the IDT meetings regarding a minor's plan of care and progress;

(8) in accordance with accepted standards of professional practice:

(A) administering medication, intravenous infusions, parenteral feeding, and other specialized treatments; and

(B) monitoring and documenting the effect of medications, therapies, and progress [~~in accordance with accepted standards of professional practice~~];

(9) communicating findings to a minor's prescribing physician and the center's nursing director; and

(10) supervising the center's direct care staff.

§550.404.Licensed Vocational Nurse Qualifications.

(a) An LVN providing services on behalf of a center must have at least the following qualifications and experience:

(1) a valid LVN license [~~licensed~~] under Texas Occupations Code, Chapter 301, with no disciplinary action;

(2) valid certifications in Pediatric Cardiopulmonary [~~Cardio Pulmonary~~] Resuscitation and Basic First Aid; and

(3) one of the following:

(A) one year of pediatric specialty experience with emphasis on medically and technologically dependent minors obtained within the last consecutive five years; or

(B) sufficient skills to meet the competency and training requirements described in subsection (b) of this section. [;]

(b) A center must adopt and enforce a written policy regarding an LVN who qualifies to provide services at the center under subsection (a)(3)(B) of this section. The policy must:

(1) require an LVN qualified under subsection (a)(3)(B) of this section to complete a training program that is determined appropriate by the Director of Nursing and conducted by an RN on the LVN responsibilities described in §550.405 [~~§15.405~~ ] of this division (relating to Licensed Vocational Nurse Responsibilities) and that includes hands-on training;

(2) require, before performing the LVN responsibilities described in §550.405 [~~§15.405~~] of this division, an LVN qualified under subsection (a)(3)(B) of this section to demonstrate competency in performing the responsibilities described in §550.405 [~~§15.405~~] of this division, as determined by an RN;

(3) describe procedures for increased supervision of an LVN qualified under subsection (a)(3)(B) of this section during the training program, competency evaluation, and for three months after completion of the competency evaluation to ensure the health and safety of minors; and

(4) prohibit an LVN qualified under subsection (a)(3)(B) of this section from performing the responsibilities in §550.405 [~~§15.405~~] of this division or being included in the nursing services staffing ratio as an LVN, as described in §550.410 [~~§15.410~~] of this division (relating to Nursing Services Staffing Ratio), until the LVN completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.

(c) An LVN must meet the requirements in §550.415 [~~§15.415~~] of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 [~~§15.416~~] of this division (relating to Staff Development Program).

§550.405.Licensed Vocational Nurse Responsibilities.

(a) An LVN providing services on behalf of a center must work under the supervision of an RN and is responsible to provide, within the LVN's level of competence and scope of practice, nursing care to the center's minors as ordered in the plan of care.

(b) An LVN must be responsible for the following:

(1) maintaining compliance with the standards of nursing practice;

(2) providing nursing interventions that includes parental training, information, and education to increase a parent's confidence and competence in caring for a minor;

(3) having knowledge of the availability of community resources;

(4) participating on the IDT and in the IDT meetings regarding a minor's plan of care and progress;

(5) communicating findings to a minor's prescribing physician and an RN; and

(6) in accordance with accepted standards of professional practice:

(A) administering medication, intravenous infusions, parenteral feeding, and other specialized treatments; and

(B) monitoring and documenting the effect of medications, therapies, and progress [~~in accordance with accepted standards of professional practice~~].

§550.406.Student Nurses.

(a) If a center has an agreement with an accredited school of nursing to use the center for a portion of a student nurse's clinical experience, the student nurse may provide care under the following conditions:

(1) the agreement ensures that criminal history checks are conducted for a student nurse in accordance with §550.418 [~~§15.418~~] of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry [~~(NAR)~~ ], and Employee Misconduct Registry [~~(EMR)~~] Requirements) before a student nurse provides direct care;

(2) a student nurse is not counted in the staffing ratio required in this chapter; and

(3) one of the following:

(A) an instructor from the school is onsite, provides class supervision, and assumes responsibility for all student nursing activities at the center; or

(B) the center:

(i) assumes responsibility for supervision of all student nurses and for all student nursing activities at the center; and

(ii) meets the requirements described in subsection (b) of this section.

(b) The center must adopt and enforce written policy and procedures describing whether the center will assume responsibility for supervision of all student nurses and for all student nursing activities at the center. If a center assumes responsibility for student nurse activity, the center must:

(1) determine the appropriate level of student nurse interaction with a minor, based on the qualifications and experience of the student nurse;

(2) assign an RN to supervise a student nurse;

(3) limit RN supervision to no more than three student nurses at one time; and

(4) based on the outcomes of paragraph (1) of this subsection, determine if it is appropriate to exclude from the staffing ratio the RN assigned to supervise the student nurse activities to ensure the health and safety of minors.

§550.409.Direct Care Staff Qualifications.

(a) Direct care staff providing services on behalf of a center, must have the following qualifications:

(1) be 18 years of age or older;

(2) a high school diploma or a general equivalency degree;

(3) one of the following:

(A) one year of experience employed in a health care setting providing direct care to minors who are medically or technologically dependent;

(B) two years of experience employed in a health care, childcare, or school setting providing direct care to minors who are medically or technologically dependent;

(D) sufficient skills to meet the competency and training requirements described in subsection (b) of this section; and

(4) maintain current certification in Pediatric Cardiopulmonary [~~Cardio Pulmonary~~] Resuscitation and Basic [~~basic~~] First Aid.

(b) A [~~The~~] center must adopt and enforce written policies [~~policy~~] and procedures regarding [~~describing whether~~] direct care staff who qualify to provide services at the center under subsection (a)(3)(D) of this section. The policy must:

(1) require direct care staff who qualify under subsection (a)(3)(D) of this section to complete a training program regarding the provision of direct care to minors that:

(A) is determined appropriate by the nursing director;

(B) is conducted by an RN or LVN; and

(2) require, before providing services to a minor, direct care staff who qualify under subsection (a)(3)(D) of this section to demonstrate competency in the provision of direct care to minors as determined by an RN;

(3) describe procedures for increased supervision of direct care staff who qualify under subsection (a)(3)(D) of this section during the training program and the competency evaluation, and for six months after completion of the competency evaluation, to ensure the health and safety of minors; and

(4) prohibit direct care staff who qualify under subsection (a)(3)(D) of this section from being assigned to a minor or being included in the nursing services staffing ratio as described in §550.410 [~~§15.410~~] of this division (relating to Nursing Services Staffing Ratio) until the direct care staff completes the training program described in paragraph (1) of this subsection and demonstrates competency as described in paragraph (2) of this subsection.

(c) Direct care staff must meet the requirements in §550.415 [~~§15.415~~] of this division (relating to Staffing Policies for Staff Orientation, Development, and Training) and §550.416 [~~§15.416~~] of this division (relating to Staff Development Program).

§550.410.Nursing Services Staffing Ratio.

(a) A center's total staffing for nursing services must be maintained, at a minimum, in the [~~following~~] ratios described in subsection (d)(2) of this section [~~but at no time must there be less than one staff member on duty per three minors receiving nursing services from a center~~]. If only one staff member is on duty, that member must be an RN.

(b) The staffing ratio is based on the number of minors on the center's actual census that are receiving nursing services from the center.

(c) A center must not include direct care staff who qualify under §550.409(a)(3)(D) [~~subsection (b) of §15.409~~] of this division (relating to Direct Care Staff Qualifications) in the staffing ratio until the staff complete the training program and demonstrate competency as described in §550.409(b)(1) and (2) [~~subsection (b)(3) of §15.409~~] of this division.

(d) A center must maintain documentation to support compliance with this section and §550.803 [~~§15.803~~ ] of this subchapter [~~chapter~~] (relating to Census). Documentation must include:

(1) each change in the number of minors on the center's actual census that are receiving nursing services from the center; and

(2) the increase or decrease in the number of RNs, LVNs, and direct care staff in accordance with this section as changes in the number of minors on the center's actual census that are receiving nursing services from the center occurs.

Figure: 26 TAC §550.410(d)(2) (.pdf)

[~~Figure: 40 TAC §15.410(d)(2)~~]

§550.411.Rehabilitative and Ancillary Professional Staff and Qualifications.

(a) If the following staff provide [~~will be providing~~] services on behalf of a center or supervise [~~supervising~~] services at a center, the staff must have one year of experience in [of] pediatric care in a health care setting. The staff may be:

(1) an audiologist with a valid license under Texas Occupations Code, Chapter 401;

(2) an occupational therapist with a valid license under Texas Occupations Code, Chapter 454;

(3) an occupational therapist assistant with a valid license under Texas Occupations Code, Chapter 454;

(4) a physical therapist with a valid license under Texas Occupations Code, Chapter 453;

(5) a physical therapist assistant with a valid license under Texas Occupations Code, Chapter 453;

(6) a respiratory therapist with a valid license under Texas Occupations Code, Chapter 604;

(7) a speech-language pathologist with a valid license under Texas Occupations Code, Chapter 401;

(8) a licensed assistant in speech-language pathology with a valid license under Texas Occupations Code, Chapter 401; or

(9) a social worker with a valid license under Texas Occupation Code, Chapter 505.

(b) A center must employ or contract with a qualified dietitian who has a valid license under the laws of the State of Texas to use the title of licensed dietitian or provisional licensed dietitian, or who is a registered dietitian with one year of supervisory experience in dietetic service.

(c) If a center has a qualified pharmacist on a full-time, part-time, or consultant basis, the pharmacist must have a valid license under Texas Occupations Code, Chapter 558.

(d) A rehabilitative professional providing services on behalf of a center or supervising services at a center must be supervised by a center's qualified licensed person who practices under the center's policies and procedures.

(e) A center must not include rehabilitative professionals in the staffing ratios.

§550.413.Contractors.

(a) If a center uses contractors, the center must enter into a contract with each contractor. The contract must be enforced by the center and clearly designate:

(1) that minors are accepted for care only by the center;

(2) the services to be provided by the contractor and how they will be provided, including per visit or per hour;

(3) the necessity of the contractor to conform to all applicable center policies, including staff qualifications;

(4) the contractor's responsibility for participating in developing the plan of care;

(5) the manner in which services will be coordinated and evaluated by the center in accordance with §550.802 [~~§15.802~~] of this subchapter (relating to Coordination of Services); and

(6) the procedures for:

(A) submitting information and documentation by the contractor in accordance with the center's record policies;

(B) scheduling of visits by the contractor or the center; and

(b) A center must establish and maintain a contract management record system to ensure that services provided to each minor by a contractor at the center are completely and accurately documented, readily accessible and systematically organized to facilitate the compilation, retrieval, and review of the information.

(c) The center is not required to maintain a personnel record for contractors. Upon request by HHSC [~~DADS~~], a center must provide documentation at the site of a survey no later than eight working hours after [of] the request to demonstrate:

(1) that contractors meet the center's written job qualifications for the position and duties performed; and

(2) the center is in compliance with §550.418 [~~§15.418~~] of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry [~~(NAR)~~ ], and Employee Misconduct Registry [~~(EMR)~~] Requirements).

§550.415.Staffing Policies for Staff Orientation, Development, and Training.

(a) A center must adopt and enforce [a] written staffing policies and procedures that govern all staff providing services on behalf of the center, including employees, volunteers, and contractors.

(b) A center's written staffing policies must include:

(1) requirements for orientation to the policies, procedures, and objectives of the center;

(2) requirements and procedures for processing criminal history checks;

(3) requirements that staff are current on immunizations;

(4) requirements that an applicant for employment provide written documentation to rule out communicable diseases, including but not limited to tuberculosis;

(5) requirements for direct care staff to demonstrate the necessary skills and competency to meet the direct care needs of a minor to which he or she is assigned and as described in their job description;

(6) requirements for staff to participate in appropriate employee development programs quarterly;

(7) requirements for participation by all staff in job-specific training;

(8) staff training policies that ensure:

(A) staff are properly oriented to tasks performed;

(B) demonstration of competency for tasks when competency cannot be determined through education, license, certification, or experience;

(C) quarterly continuing systemic training for all staff who provide services, including training on infection prevention and control;

(D) staff are informed of changes in techniques, philosophies, organization, minor's rights, ethics and confidentiality, medical record requirements, information relating to minor's development, goals, and products relating to a minor's care;

(E) staff are properly oriented and trained in the proper use of person-centered direction and guidance as outlined in center policy and in accordance with §550.206 [~~§15.206~~ ] of this subchapter (relating to Person-Centered Direction and Guidance);

(F) staff are properly oriented and trained in the proper use and application of protective devices; and

(G) staff are properly oriented and trained in the proper use and application of restraints in accordance with the following requirements:

(i) all center staff whose job responsibilities include the use of restraint during a behavioral emergency must be trained before assuming direct care responsibilities for a minor;

(ii) all center staff must receive training and demonstrate competency in the following areas:

(I) using any restraint techniques or procedures that are expected or anticipated to be employed;

(II) identifying the underlying causes or functions of threatening behaviors;

(III) understanding how the behavior of staff members affects the behavior of minors;

(IV) using de-escalation, mediation, self-protection, and other techniques, such as quiet time, to prevent or reduce the use of restraint;

(V) applying principles of trauma informed care; and

(VI) recognizing and responding to signs of distress in a minor who is being restrained; and

(iii) all center staff must complete training and demonstrate competence in the use of restraint in a behavioral emergency at least every 12 months following initial training; and

(H) job-specific training is documented with the following information:

(i) the name and qualifications of the trainer;

(ii) the training topics and length; and

(iii) a list of staff who completed the training and demonstrated competence;

(9) a requirement to have a written job description that is a statement of the functions and responsibilities, and job qualifications, including the specific education and training requirements for each position at the center;

(10) procedures for searching the nurse aide registry and the employee misconduct registry for staff in accordance with §550.418 [~~§15.418~~] of this division (relating to Criminal History Checks, Nurse Aid Registry, Medication Aide Registry [~~(NAR)~~], and Employee Misconduct Registry [~~(EMR)~~] Requirements);

(11) a requirement to have annual evaluation of employee and volunteer performance;

(12) a description of employee and volunteer disciplinary action and procedures;

(13) a policy regarding the use of volunteers that is in compliance with §550.414 [~~§15.414~~] of this division (relating to Volunteers); and

(14) a requirement that all staff providing services on behalf of a center sign a statement that the staff have read, understand, and will comply with all applicable center policies.

(c) A center must adopt and enforce written policies and procedures for parent orientation and training programs in accordance with §550.509 [~~§15.509~~] of this subchapter (relating to Parent Training). The policy must:

(1) require orientation be provided to each parent of each minor admitted to the center; and

(2) ensure that orientation includes:

(A) the philosophy of the center;

(B) the basic services as defined in §550.5 of this chapter (relating to Definitions);

(D) a minor's parent agreement and disclosure form;

(E) the center attendance policy for minors; and

(F) information about a minor's rights while receiving services at the center.

§550.417.Personnel Records.

(a) A center must maintain a personnel record for an employee and volunteer. A personnel record may be maintained electronically if it meets the same requirements as a paper record. All information must be kept current. A personnel record must include the following:

(1) a signed job description and qualifications for each position accepted or a signed statement that the person read the job description and qualifications for each position accepted;

(2) an application for employment or volunteer agreement;

(3) a record of the immunizations requirements and evaluation of the tuberculosis results;

(4) verification of references, job experience, and educational requirements as conducted by the center to verify qualifications for each position accepted;

(5) verification of licenses, permits, and certifications before employment and annually;

(6) annual performance evaluations and disciplinary actions;

(7) the signed statement about compliance with center policies required by §550.415 [~~§15.415~~] of this division (relating to Staffing Policies for Staff Orientation, Development, and Training); and

(8) for an employee and volunteer:

(A) a printed copy of the results of the initial and annual searches of the nurse aide registry and employee misconduct registry obtained from the HHSC [~~DADS~~] Internet website; and

(B) documentation that the employee, volunteer, or contractor in accordance with §550.418 [~~§15.418~~ ] of this division (relating to Criminal History Checks, Nurse Aide Registry, Medication Aide Registry [~~(NAR)~~], and Employee Misconduct Registry [~~(EMR)~~] Requirements) received written information about the Employee Misconduct Registry [~~EMR~~].

(b) A center must keep a complete and accurate personnel record for an employee and volunteer at its licensed location.

§550.418.Criminal History Checks, Nurse Aide Registry, Medication Aide Registry [~~(NAR)~~], and Employee Misconduct Registry [~~(EMR)~~] Requirements.

(a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.

(1) Applicant means any individual applying for a position in a center.

(2) Employee means an individual directly employed by a center, a volunteer, or a contractor.

(b) The provisions in this subsection apply to an applicant and an employee.

(1) A center must conduct a criminal history check authorized by, and in compliance with, THSC Chapter 250 for an applicant for employment and an employee.

(2) A center must not employ an applicant whose criminal history check includes a conviction listed in THSC §250.006 that bars employment or a conviction the center has determined is a contraindication to employment. If an applicant's or employee's criminal history check includes a conviction of an offense that is not listed in THSC §250.006, the center must document its review of the conviction and its determination of whether the conviction is a contraindication to employment.

(3) The center must immediately discharge an employee when the center becomes aware that the employee's criminal history check reveals conviction of a crime that bars employment or that the center has determined is a contraindication to employment.

(1) Before a center hires an applicant, the center must search the Nurse Aide [~~Aid~~] Registry (NAR), Medication Aide Registry (MAR), and [~~the~~] Employee Misconduct Registry (EMR) using the HHSC [~~DADS~~] website to determine if an applicant or employee is listed in any of these registries [~~either registry~~] as unemployable. The center must not employ an applicant who is listed as unemployable in any of these registries [~~either registry~~].

(2) The center must provide information about the EMR to an employee no later than five business days after hiring an employee. The information must:

(A) be in writing;

(B) state that a person listed in the EMR is not employable by the center; and

(C) include a reference to Chapter 561 [93 ] of this title (relating to Employee Misconduct Registry [~~(EMR)~~ ]) and THSC Chapter 253.

(3) In addition to the initial verification of employability, the center must search the NAR and the EMR to determine if the employee is listed as unemployable in either registry at least every 12 months.

(4) A center must suspend the employment of an employee who HHSC finds has engaged in reportable conduct while the employee exhausts any applicable appeals process, including informal and formal appeals and any hearing or judicial review, in accordance with THSC §253.004 or §253.005, pending a final decision by an administrative law judge. A center must not reinstate the employee's employment or contract during the course of any applicable appeals process.

(5) [~~(4)~~] The center must immediately discharge an employee when the center becomes aware:

(A) that the employee is designated in the NAR or the EMR as unemployable; or

(B) that the employee's criminal history check reveals conviction of a crime that bars employment or that the center has determined is a contraindication to employment.

(d) Upon request by HHSC [~~DADS~~], a center must provide documentation to demonstrate compliance with subsections (b) and (c) of this section.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402398

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 4. GENERAL SERVICES

26 TAC §§550.504, 550.506 - 550.508, 550.510, 550.511

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.504.Psychosocial Treatment and Services.

(a) A center must ensure the provision of psychosocial treatment based on the needs of a minor, in accordance with a minor's plan of care and as ordered by a minor's prescribing physician.

(b) If psychosocial treatment and services are provided at the center, the center must ensure that the provision of psychosocial treatment and services complies with the requirements of this section, §550.206 [~~§15.206~~] of this subchapter (relating to Person-Centered Direction and Guidance) and §550.207 [~~§15.207~~] of this subchapter (relating to Protective Devices and Restraints) as applicable to a minor's plan of care and physician's order.

(c) The center must ensure psychosocial treatments and services provided at a center are overseen by a physician, RN, or psychologist.

(d) If psychosocial treatments and services are provided in a center, the center must adopt and enforce written policies and procedures relating to the provision of psychosocial treatments to a minor, including:

(1) ensuring the development of interventions to foster normal development;

(2) ensuring the development of interventions to foster psychosocial adaptations;

(3) using person-centered direction and guidance in accordance with §550.206 [~~§15.206~~] of this chapter; and

(4) using restraints in accordance with §550.207 [~~§15.207~~] of this subchapter.

(e) If psychosocial treatments are provided in a center, the center must ensure the initial health assessment of a minor receiving psychosocial treatments includes:

(1) mental status including psychological and behavioral status;

(2) sensory and motor function;

(3) cranial nerve function;

(4) language function; and

(5) any other criteria established by a center's policy.

(f) The center must ensure that an individual providing psychosocial treatment and services in a center:

(1) actively participates in the coordination of a minor's care, in accordance with accepted standards of practice;

(2) participates in ongoing interdisciplinary comprehensive assessments and developing and evaluating the plan of care;

(3) participate as a committee member in the continuous review of the center's person-centered direction and guidance program in accordance with §550.206 [~~§15.206~~] of this subchapter;

(4) provides assistance to a minor's family with the effects of chronic illness and supporting effective relationships within a family; and

(5) develops interventions to foster normal development and psychosocial adaptation.

§550.506.Rehabilitative Services.

(a) A center must ensure the provision of rehabilitative services based on the needs of a minor, in accordance with a plan of care and as ordered by a minor's prescribing physician.

(b) The center must ensure rehabilitative services provided at a center are overseen by a licensed or certified qualified professional staff as specified in §550.411 [~~§15.411~~ ] of this subchapter (relating to Rehabilitative and Ancillary Professional Staff and Qualifications).

(1) actively participates in the coordination of a minor's care, in accordance with accepted standards of practice; and

(2) participates in ongoing interdisciplinary comprehensive assessments, and in developing and evaluating the plan of care.

§550.507.Functional Developmental Services.

(a) A center must ensure the provision of functional developmental services based on the needs of a minor, in accordance with the minor's plan of care and as ordered by a minor's prescribing physician.

(b) A center must refer a minor to Early Childhood Intervention, within seven days after identification of a developmental delay or risk of developmental delay in accordance with 34 Code of Federal Regulations [~~, Title 34,~~] §303.303 Referral procedures [~~(relating to Referral Procedures)~~].

(c) A center must ensure that each minor has a functional assessment incorporated into the comprehensive assessment to include developmentally appropriate areas.

(d) A minor's functional assessment must include:

(1) measurable goals that enhance independent functioning in daily activities and to promote socialization;

(2) a description of a minor's strengths and present performance level with respect to each goal;

(3) skills areas in priority order; and

(4) planning for specific areas identified as needing development.

§550.508.Educational Developmental Services.

(a) The center must adopt and enforce written policies and procedures to facilitate each minor's access to available early intervention and educational services and programs delivered by an education provider, including a local education agency (LEA), as defined in United States Code, Title 20, §1401(19), [~~§1401(15), (LEA),~~] early childhood intervention agency, or private school, in the least restrictive environment in the community where a minor resides and where the center is located. The center's educational policy must:

(1) be person-centered and parent driven;

(2) be collaborative with the education provider;

(3) ensure that the center does not act as the primary education provider for a minor or accept a delegation of responsibility for the provision of a minor's education from an education provider; and

(4) support a minor's education program as agreed to by a parent and education provider.

(b) The center must not coerce or provide an incentive to an individual or education provider that would result in a minor's removal from a less restrictive educational environment.

(c) The center must not be the primary location for the education provider to deliver services to a minor unless it is determined by the education provider, including the LEA's Admission, Review, and Dismissal (ARD) committee or committee required by Section 504 of the Rehabilitation Act of 1973, in collaboration with a minor's parent and a minor's prescribing physician that the center is the least restrictive environment for a minor to receive educational services.

(d) For a minor who is not receiving services from an education provider, the center must provide a minor and a minor's parent contact information for the LEA where a minor resides.

(e) For a minor receiving services from an education provider, the center must:

(1) not duplicate or provide services that conflict with a minor's education program;

(2) for a minor receiving services from an LEA, not interfere with the compulsory attendance requirements of Texas Education Code §25.085 and §25.086;

(3) when requested by a parent, make available a minor's records to support the minor's education program;

(4) request copies of a minor's education program records to support center care planning activities;

(5) if requested by a parent, participate in planning activities for a minor conducted by the education provider, including an LEA's ARD committee or committee required by Section 504 of the Rehabilitation Act of 1973;

(6) request that a minor's teacher, or other education provider representative, participate as part of the IDT to ensure coordination of a minor's services with the scheduled education component of activities; and

(7) support a minor's education program activities at the center, if needed, by:

(A) providing a well-lighted room, private space or other adequate workspace;

(B) providing functional assistance to a minor;

(C) coordinating with a minor and a minor's parent to ensure special and general supplies and equipment available for a minor if needed; and

(D) providing an area to post education program calendars and information bulletins provided to the center for minors and parents to view.

§550.510.Nutritional Counseling.

(a) A center must ensure the provision of nutritional counseling as defined in §550.5 [~~§15.5~~] of this chapter (relating to Definitions) based on the minor's needs and in accordance with the minor's plan of care.

(b) Nutritional counseling must be overseen by a qualified individual including a dietitian, a nutritionist, or an RN.

§550.511.Dietary Services.

(a) A center must adopt and enforce written policy and procedures to ensure that a minor, while at the center, receives:

(1) a nourishing, well-balanced diet as recommended by the American Academy of Pediatrics or Food and Nutrition Board of the National Research Council, National Academy of Sciences; or

(2) a diet ordered by a minor's prescribing physician.

(b) If a minor's meals and snacks are supplied by an adult minor or a minor's parent, the center's written policy and procedures must:

(1) include a written signed agreement between the center and the adult minor or minor's parent that includes:

(A) a statement that the adult minor or minor's parent is responsible for providing the appropriate meals and snacks for the minor in accordance with this section;

(B) the responsibilities of the center and the responsibilities of the adult minor or minor's parent concerning the provision of meals and snacks; and

(C) actions that may be taken by the center if the adult minor or minor's parent fails to provide meals and snacks for the minor as agreed;

(2) describe the actions that will occur if an adult minor or minor's parent fails to provide the minor's meals and snacks or fails to provide meals and snacks in accordance with the minor's prescribed diet, which must include that the center ensures that the minor receives the meals and snacks as required in this section while at the center; and

(3) ensure an adult minor or minor's parent receives nutritional counseling as described in §550.510 [~~§15.5101~~ ] of this division (relating to Nutritional Counseling).

(c) If the center provides meals and snacks directly or under contract, the center must employ or contract with a dietitian as described in §550.411(b) [~~§15.411(b)~~] of this subchapter (relating to Rehabilitative and Ancillary Professional Staff and Qualifications).

(1) The dietitian is responsible for the overall operation of the dietary service.

(2) The dietitian must participate in regular conferences with the administrator and nursing director to provide information about approaches to identified nutritional problems.

(3) The dietitian must participate in the development of dietary support staff policies.

(4) The center must employ sufficient dietary support staff who meet the qualifications to carry out the functions of the dietary service.

(5) The dietitian must ensure that a minor has a diet:

(A) that meets the daily nutritional and special dietary needs of a minor, based upon the acuity and clinical needs of a minor; or

(B) as prescribed by a minor's prescribing physician.

(6) The dietitian is required to review a minor's plan of care for any known food allergy and special diet ordered by a minor's prescribing physician as often as necessary for changes to a minor's dietary needs.

(d) If a center provides meals and snacks directly or under contract:

(1) a dietitian must develop a menu that:

(A) is prepared at least one week in advance;

(B) is written for each type of diet; and

(2) the center must post the current week's menu in a conspicuous location so an adult minor and a minor's parent may see it; and

(3) the center must retain menus for 30 days.

(e) If a center provides meals and snacks directly, the center must retain records of menus served and food purchased for 30 days. The center must keep a list of minors receiving special diets and a record of the diets in the minors' medical records for at least 30 days.

(f) The center must:

(1) provide tables that allow minors to eat together when possible;

(2) provide assistance to minors, as needed;

(3) serve food on appropriate tableware; and

(4) ensure clean napkins, bibs, dishes, and utensils are available for each use.

(g) A center must coordinate with an adult minor or a minor's parent to ensure special eating equipment and utensils are available for a minor at the center if needed.

(h) An identification system, such as tray cards, must be available to ensure that all food is served in accordance with a minor's diet.

(i) A center must monitor and record food intake of all minors as follows.

(1) Deviations from normal food and fluid intake must be recorded in a minor's medical record.

(2) In-between meal snacks, and supplementary feedings, either as a part of the overall plan of care or as ordered by a minor's prescribing physician, including special diets, must be documented using professional practice standards.

(j) The center must serve a minor meals and snacks as specified in this section and as outlined in a minor's plan of care.

(1) If breakfast is served, a morning snack is not required.

(2) Notwithstanding the provisions of this section, a minor must not go more than three hours without a meal or snack being offered, unless a minor is sleeping.

(3) The center must offer at least one snack to a minor who is served at the center for less than four hours.

(4) The center must offer one meal, or one meal and one snack, equal to one third of a minor's daily food needs to a minor who is served at the center for four to seven hours.

(5) The center must offer two meals and one snack, or two snacks and one meal, equal to one half of a minor's daily food needs to a minor who is served at the center for more than seven hours.

(6) The center must ensure that a supply of drinking water is always available to each minor and is served at every snack, mealtime, and after active play.

(k) The center must:

(1) purchase food from sources approved or considered satisfactory by federal, state, and local authorities;

(2) store, prepare, and serve food under sanitary conditions, as required by the Texas Department of State Health Services food service sanitation requirements; and

(3) dispose of garbage and refuse properly.

(l) The center must provide safe and proper storage and service of a minor's meals and snacks provided by an adult minor and a minor's parent.

(m) Dietary service staff must be in good health and practice hygienic food-handling techniques. Staff with symptoms of communicable diseases or open, infected wounds may not work at the center until the center receives written documentation from a health care professional that the staff member is released to return to work or, the signs and symptoms which relate to the communicable disease are no longer evident.

(n) Dietary service staff must wear clean, washable garments, wear hair coverings or clean caps, and have clean hands and fingernails.

(o) Routine health examinations must meet all local, state, and federal codes for food service staff.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402399

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 5. ADMISSION CRITERIA, CONFERENCE, ASSESSMENT, INTERDISCIPLINARY PLAN OF CARE, AND DISCHARGE OR TRANSFER

26 TAC §§550.601 - 550.608

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.601.Admission Criteria.

(a) A center may admit a minor if:

(1) the minor's prescribing physician, in consultation with the minor's parent and the minor, recommends admission to a center, taking into consideration the medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, education, and development needs of the minor in addition to the emotional, psychosocial, and environmental factors;

(2) the minor's prescribing physician issues a prescription ordering care at a center;

(3) the minor is stable for outpatient medical services and requires ongoing nursing care and other basic services;

(4) the adult minor or the minor's parent signs a written agreement and disclosure form consenting to the adult minor's or minor's admission to a center; and

(5) the admission is voluntary.

(b) The center must ensure that its admission criteria are in accordance with §550.211 [~~§15.211~~] of this subchapter (relating to Infection Prevention and Control Program and Vaccinations Requirements).

§550.602.Pre-admission Conference.

(a) If a minor meets the criteria for admission into a center as described in §550.601 [~~§15.601~~] of this division (relating to Admission Criteria), the medical or nursing director must contact the minor's prescribing physician to schedule a pre-admission conference before the minor receives services at the center.

(b) If a minor is hospitalized at the time of referral to a center, the pre-admission conference must include the minor's parent, the minor, the minor's prescribing physician, center staff, relevant hospital staff, including medical, nursing, social services, and developmental staff, and any other individuals requested by the adult minor or the minor's parent, to begin developing the plan of care.

(c) If a minor is not hospitalized at the time of referral to a center, the pre-admission conference must include the minor's parent, the minor, the minor's prescribing physician, center staff, and any other individuals requested by the adult minor or the minor's parent to begin developing the plan of care.

(d) A center must schedule a pre-admission conference no later than three days after the center receives a [~~receipt of the~~] referral. The pre-admission conference must address a minor's:

(1) medical history;

(2) diagnosis;

(3) mental and developmental status;

(4) nutritional status;

(5) dietary requirements;

(6) functional abilities and limitations;

(7) activities permitted and prohibited;

(8) use of assistive devices;

(9) treatment procedures;

(10) use of restraints, if applicable;

(11) medication;

(12) safety measures to protect against injury;

(13) education level and participation in an education program, if applicable;

(14) immunization record;

(15) receipt of services from other service providers; and

(16) other appropriate information.

§550.603.Agreement and Disclosure.

(a) A center must review a written agreement and disclosure form with a minor's parent or with an [~~the~~] adult minor before services are provided at the center.

(b) The agreement and disclosure form must include evidence or attestation that the parent of a minor has the legal authority to consent to the [a] minor's medical care.

(c) The agreement and disclosure form must document that a center obtained a minor's parent's or an adult minor's written informed consent specifying the services that may be provided on behalf of a center to a minor.

(d) The agreement and disclosure form must document that the center provided the following information orally and in writing to a [~~the~~] minor's parent or the minor, or an adult minor, in a language or format the minor [~~he or she~~] understands:

(1) the notice of rights and responsibilities described in §550.901 [~~§15.901~~] of this subchapter (relating to Rights and Responsibilities);

(2) information on the Advance Directives Act, THSC, Chapter 166;

(3) the extent to which payment for services provided on behalf of the center may be expected from any third-party payment source known to a center, the charges for services not covered by a third-party payment source and charges that a minor's parent or adult minor may have to pay;

(4) a list of the staff who will provide services on behalf of the center;

(5) a list of expected outcomes and any specific limitations or barriers to reaching the outcomes;

(6) the method of supervision and oversight by a center of the services to be provided at the center;

(7) the HHSC [~~DADS~~] toll-free telephone number and its purpose;

(8) the process for directing a grievance to the administrator about services provided at the center and the time frame in which the center must review and resolve a grievance;

(9) the [an] adult minor's and the minor's [a] parent's responsibilities;

(10) an emergency plan for a minor; and

(11) notice of the center's policies regarding:

(A) attendance requirements;

(B) implementing an advance directive in accordance with §550.902 [~~§15.902~~] of this subchapter (relating to Advance Directives);

(D) person-centered direction and guidance;

(E) restraints;

(F) reporting abuse, neglect, or exploitation of a minor by an employee, volunteer, or contractor;

(G) drug testing of employees in direct contact with a minor in accordance with §550.419 [~~§15.419~~] of this subchapter (relating to Drug Testing Policy); and

(H) management and disposal of medications in the center.

(e) The agreement and disclosure form must be signed by a minor's parent or an adult minor.

(f) A center must provide a signed copy of the agreement and disclosure form to the minor's parent or the adult minor.

(g) The center must keep the signed written agreement and disclosure form in the minor's medical record.

(h) The center must update the agreement and disclosure form if information in the form changes.

(i) The center must comply with the terms of the agreement.

§550.604.Admission Procedures.

(a) A center's administrator, nursing director, or designee must conduct an interview with a minor's parent or an adult minor before or at a minor's admission to the center that addresses the following:

(1) the adult minor's and minor's parent's rights and responsibilities;

(2) the center's policies and procedures;

(3) basic services;

(4) the center's dietary services;

(5) the center's transportation services;

(6) the center's operating hours and contact information;

(7) the center's infection prevention and control program;

(8) the center's emergency preparedness plan;

(9) the center's attendance policy;

(10) services the minor is receiving at the center, but not provided by the center;

(11) development of the minor's plan of care;

(12) the minor's emergency plan and needs; and

(13) the minor's transfer and discharge planning.

(b) A center must request and keep a copy of a minor's medical history and documentation of a physical examination performed by the [a] minor's prescribing physician within 30 days before or after the date of the minor's admission to the center.

(c) A center must have a signed order from a [~~the~~] minor's prescribing physician on the day of the minor's admission, as described in §550.701 [~~§15.701~~] of this subchapter (relating to Physician Orders).

§550.605.Initial and Updated Comprehensive Assessment.

(a) A center's RN must conduct and document a specific initial comprehensive assessment that identifies the minor's medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional abilities, educational, and developmental needs and the adult minor's or minor's parent's training needs.

(b) The initial comprehensive assessment must include the minor's discharge planning, including transition support, self-advocacy guidance, and coordination of services required by the minor and the minor's parent.

(c) The initial comprehensive assessment must be conducted in consultation with an adult minor and the [a] minor's parent [~~and the minor, if the minor is an adult minor~~].

(d) An RN must complete an initial comprehensive assessment no earlier than three business days before the minor is admitted to the center and no later than the date the minor is admitted to the center.

(e) An RN must conduct, in consultation with a minor's parent or an [~~the~~] adult minor, a comprehensive assessment of the minor at least once every 180 days after admitting the minor into the center. An RN must conduct a new comprehensive assessment on the minor when the minor has a change of condition or the minor's needs change.

(f) The updated comprehensive assessment described in subsection (e) of this section must:

(1) identify a minor's ongoing medical, nursing, psychosocial, therapeutic, nutritional, dietary, functional, educational, and developmental needs and the training needs of the adult minor or parents of the minor [~~minor's and a minor's parent's training needs~~]; and

(2) include a minor's discharge planning, detailing transition support, if needed, self-advocacy guidance, and coordination with the minor's parent or the adult minor.

§550.606.Interdisciplinary Team.

(a) A center must designate an IDT.

(b) The IDT must monitor the services provided to a [~~the~~] minor at the center.

(1) provide coordination of care for the minor;

(2) ensure continuous assessment of the minor's and the minor's parent's needs; and

(3) implement the minor's interdisciplinary plan of care.

(d) The IDT must prepare a written plan of care for the minor as described in §550.607 [~~§15.607~~] of this division (relating to Initial and Updated Plan of Care).

(e) The IDT must include:

(1) the minor's prescribing physician;

(2) the center's nursing director or an RN designated by the nursing director;

(3) the minor;

(4) the minor's parent;

(5) a social worker, if the minor is receiving social services at the center; and

(6) another individual providing basic services to a minor if the minor is receiving basic services other than nursing services at the center.

(f) The IDT must participate in the development of a plan of care with goals and objectives for a minor that includes discharge planning when goals and objectives are met.

§550.607.Initial and Updated Plan of Care.

(a) A center must develop an individualized written plan of care for a minor. The plan of care must include:

(1) the minor's and the minor's parent's goals and interventions based on the issues identified in the pre-admission conference and the initial and updated comprehensive assessments; and

(2) measurable goals with interventions based on the minor's care needs and means of achieving each goal and must address, as appropriate, rehabilitative and restorative measures, preventive intervention and training, and teaching of personal care by the minor's parent.

(b) An RN must address in the written interdisciplinary plan of care:

(1) the services needed to address the medical, nursing, psychosocial, therapeutic, dietary, functional, educational, and developmental needs of the minor and the training needs of the minor's parent;

(2) the minor's functional assessment;

(3) the specific goals of care;

(4) the time frame for achieving the goals and the schedule for evaluation of progress;

(5) the orders for treatment, services, medications, medical equipment, diet, and restraints, if applicable;

(6) specific criteria for transitioning from or discontinuing participation at the center; and

(7) the minor's scheduled days of attendance.

(c) In collaboration with the interdisciplinary team, an RN, a minor's parent, the minor, and an individual requested by the adult minor or the minor's parent must develop a plan of care based on the comprehensive assessment.

(d) The RN, an adult minor, and a minor's parent [~~and the minor, if the minor is an adult minor,~~] must sign the plan of care within five days after initiation of the plan.

(e) A minor's prescribing physician must review and sign the plan of care within 30 days after initiation of the plan.

(f) The center must incorporate the plan of care into a minor's medical record no later than 10 days after receiving the signed plan from a minor's prescribing physician.

(g) Copies of the plan of care must be given, in a language and format the recipient understands, to a minor's parent, an adult minor, the minor's prescribing physician, the center's staff, and other health care providers and providers of basic services as appropriate.

(h) The center's IDT and an RN must review and update a minor's plan of care at least every 180 days, or more often, if there is a change in the [a] minor's medical condition or changes in the [a] minor's needs.

(i) A minor's parent and an adult minor [~~and the minor, if the minor is an adult minor,~~] must review and sign the updated plan of care within five days before changes to the plan of care are implemented.

(j) A minor's prescribing physician must review and sign the updated plan of care within 30 days after initiation of the updated plan.

(k) The center must incorporate the updated plan of care into a minor's medical record no later than 10 days after receiving the signed plan from the [a] minor's prescribing physician.

(l) The center must adopt and enforce written policies and procedures regarding the communication and coordination of a minor's care with the [a ] minor's prescribing physician in accordance with the plan of care.

(m) The policy described in subsection (l) of this section must ensure the communication between the center's staff and a [~~the~~] minor's prescribing physician is conveyed to the minor's parent and the minor in a language and format that the [an] adult minor and minor's parent understand.

(n) The center's nursing director or designee must:

(1) document communication with a [~~the~~] minor's prescribing physician;

(2) maintain the documentation in the minor's medical record; and

(3) ensure that the communication is conveyed to the minor's parent and the adult minor in a language and format the adult minor and minor's parent understand.

(o) The center staff must ensure the provision of services and treatments in accordance with the plan of care and as ordered by a [~~the~~] minor's prescribing physician.

§550.608.Discharge or Transfer Notification.

(a) A center intending to transfer or discharge a minor must provide both oral and written notification to the [a ] minor's parent and adult minor no later than 15 days before the date the minor will be transferred or discharged, if the notification is provided in person.

(b) If the center does not provide the notice of transfer or discharge in person, the center must provide oral notification to a minor's parent and adult minor by telephone no later than 15 days before the date of transfer or discharge and mail the written notification no later than 15 days before the date of transfer or discharge.

(c) A center that intends to transfer or discharge a minor must also notify the minor's prescribing physician no later than 15 days before the date the minor will be transferred or discharged.

(d) A center may transfer or discharge a minor without providing the oral and written notification described in subsections (a) and (b) of this section:

(1) if the minor's parent or adult minor requests the transfer or discharge;

(2) if the minor's medical needs require transfer, including a medical emergency;

(3) if the minor's health and safety is at risk due to an emergency and a transfer is made in accordance with §550.209 [~~§15.209~~] of this subchapter (relating to Emergency Preparedness Planning and Implementation);

(4) for the protection of staff or a minor attending the center after the center makes a documented, reasonable effort to notify the minor's parent, the minor's prescribing physician, and appropriate state or local authorities of the center's concerns for the safety of staff or the minor, and in accordance with center policy;

(5) according to the minor's prescribing physician's orders; or

(6) if the minor's parent or an adult minor fails to pay for services, except as prohibited by state law.

(e) A center must keep in a minor's medical record:

(1) a copy of the written notification provided in accordance with subsection (a) or (b) of this section to the minor's parent or adult minor;

(2) documentation of the personal contact with the minor's parent or adult minor in accordance with subsection (b) of this section; and

(3) documentation that the minor's prescribing physician was notified of the date of transfer or discharge in accordance with subsection (c) of this section.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402400

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 6. PHYSICIAN, PHARMACY, MEDICATION, AND LABORATORY SERVICES

26 TAC §§550.701, 550.703, 550.705, 550.707

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.701.Physician Orders.

(a) A center must ensure that a minor admitted to the center is admitted under an order of the minor's prescribing physician and remains under the care of the prescribing physician for the duration of the minor's stay at the center. The minor's medical record must contain the written prescribing physician order used for admission as well as all subsequent prescribing physician orders.

(b) The prescribing physician orders must include:

(1) approval of a minor's admission to a center;

(2) nursing services;

(3) medication administration, if applicable;

(4) dietary needs, if applicable;

(5) permitted activities, if applicable;

(6) therapy [~~therapies~~] treatments, if applicable;

(7) transportation authorization, if applicable; and

(8) other services, if applicable.

§550.703.Pharmacist Services.

(a) If a center administers or stores medication, the center must have a pharmacist or a qualified RN with education and training in drug management [~~and~~] on a full-time, part-time, or on a consultant basis to provide consultation to the medical director, administrator, nursing director, and other center staff.

(b) A center must consult with a pharmacist or qualified RN as needed on the following:

(1) establishing written policies and procedures for the storage and administration of medications as described in §550.704 [~~§15.704~~] of this division (relating to Storage of Medication) and §550.705 [~~§15.705~~] of this division (relating to Administration of Medication);

(2) reviewing medical records to ensure that the medication records are accurate, updated, and reflect that medications are administered in accordance with the orders of a minor's prescribing physician;

(3) providing in-service training to staff on the storage and administration of medications; and

(4) ensuring pharmaceutical compliance.

§550.705.Administration of Medication.

(a) A center must adopt and enforce written policies and procedures for the administration of medication to a minor. The policies and procedures must address:

(1) removing an individual dose from a previously dispensed, properly labeled container;

(2) verifying the medication with the prescriber's orders;

(3) verifying the order with the correct minor;

(4) giving the correct medication dose to a minor;

(5) giving the medication by the correct route;

(6) observing that the medication is taken;

(7) recording the required information, including the method of administration; and

(8) documenting any medication not administered and the reason.

(b) A center's written policy must ensure compliance with:

(1) THSC Chapter 248A;

(2) this chapter;

(3) state law authorizing a person licensed under the Texas Occupations Code to administer medications;

(4) rules adopted by the Texas Board of Nursing 22 Texas Administrative Code [~~TAC~~] Chapter 224 (relating to Delegation of Nursing Tasks by Registered Professional Nurses to Unlicensed Personnel for Clients with Acute Conditions or in Acute Care Environments) governing when an RN may delegate the administration of medication to an unlicensed person; and

(5) any other applicable state and federal regulations relating to the administration of medication to a minor.

(c) If there is a direct conflict between this chapter and other applicable state and federal laws and regulations, a center must comply with the more stringent requirements.

(d) The administration of medication by center staff must be included in a minor's plan of care.

(e) A center must adopt and enforce written policies and procedures for maintaining a current medication list and a current medication administration record.

(f) A center's written policy must require center staff who supervise, assign, or delegate the administration of medication or administer medication to a minor to maintain a current medication list in the minor's medical record.

(g) A center may incorporate a current medication list and medication administration record into one document.

(h) An RN must review the medication list initially after a minor is admitted and update the list when necessary but at least every 90 days.

(i) An RN must report significant findings from a review of the medication list to the minor's prescribing physician.

(j) Review of the medication list includes evaluation of prescription and over-the-counter drugs, medication orders, and the medication list for:

(1) known allergies;

(2) rational drug therapy-contraindication;

(3) reasonable dose and route of administration;

(4) reasonable directions for use;

(5) duplication of drug therapy;

(6) drug-drug interaction;

(7) drug-food interaction;

(8) drug-disease interaction;

(9) adverse drug reaction; and

(10) proper use, including overuse or underuse.

(k) A center must adopt and enforce written policies and procedures on medication errors. The policy must ensure that the nursing director, a minor's prescribing physician and the minor's parent are notified immediately after the discovery of a medication error or an adverse reaction.

§550.707.Disposal of Special or Medical Waste.

(a) A center must adopt and enforce a written policy for the safe handling and disposal of special or medical waste and materials, including bio-hazardous waste and materials.

(b) A center that generates special or medical waste while providing services must dispose of the waste according to the requirements issued by the Texas Department of State Health Services in 25 Texas Administrative Code [~~TAC~~] Chapter 1, Subchapter K (relating to Definition, Treatment, and Disposition of Special Waste from Health Care-Related Facilities).

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402401

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 7. CARE POLICIES, COORDINATION OF SERVICES, AND CENSUS

26 TAC §550.802, §550.803

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.802.Coordination of Services.

(a) A center must adopt and enforce written policies and procedures regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of a minor's services:

(1) among all staff providing services on behalf of a center; and

(2) between the center and a provider of services to the minor that is not providing services on behalf of the center, if known by the center.

(b) Documentation in a minor's medical records must demonstrate coordination of services as described in subsection (a) of this section.

(c) For a minor receiving services from a provider that is not providing services on behalf of a center, the center must:

(1) not duplicate or provide services that conflict with the minor's care plan or service plan with the provider;

(2) when requested by an adult minor or parent, make available the minor's records to support the coordination of services between the center and the provider;

(3) request copies of the [a] minor's records with the provider to support center care planning activities;

(4) if requested by an adult minor or parent, participate in planning activities for the adult minor or [a] minor conducted by the provider;

(5) request that the [a] minor's provider participate as part of the center's interdisciplinary team and QAPI committee, as applicable; and

(6) support the coordination of the [a] minor's services by allowing the minor's provider to serve a minor at the center, if:

(A) the center, the provider, the [a] minor's parent or the adult minor[~~, a minor, if the minor is an adult minor and the provider~~] agree that the provision of services to the [a] minor by the provider at the center would be appropriate for the minor; and

(B) the center and the provider establish a written agreement that includes the provider's agreement to comply with center policies and this chapter for the provision of the provider's services at the center. [ ~~The written agreement must include the provider's compliance with center policies and this chapter.~~]

§550.803.Census.

(a) A center must adopt and enforce written policies and procedures for the development of the center's actual, daily, and total census lists.

(b) A center's written policies and procedures must address:

(1) developing and maintaining the census lists;

(2) the staff responsible for maintaining the census lists; and

(3) the retrieval of the census lists when requested by HHSC [~~DADS~~].

(1) actual census, which must be updated each time the number of minors at the center changes;

(2) daily census; and

(3) total census.

(d) The actual and daily census must include:

(1) the [a] minor's name;

(2) the services provided to the [a] minor and the provider responsible for the delivery of each service; and

(3) the time the [a] minor entered and left the center.

(e) The total census must include:

(1) the [a] minor's name;

(2) the [a] minor's diagnosis; and

(3) the name and contact information of the [a] minor's prescribing physician.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402402

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 8. RIGHTS AND RESPONSIBILITIES, ADVANCE DIRECTIVES, ABUSE, NEGLECT, AND EXPLOITATION, INVESTIGATIONS, DEATH REPORTING, AND INSPECTION RESULTS

26 TAC §§550.901 - 550.906

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.901.Rights and Responsibilities.

(a) A center must adopt and enforce written policies to ensure a minor's legal rights are observed and protected and to ensure compliance with this section. The policies must comply with relevant law and ensure that the center considers a minor's age and legal status, including whether a guardian has been appointed or the disabilities of minority have been removed, to determine the [a] minor's or other individual's authority to make decisions for the minor.

(b) Before providing services to a minor, a center must provide an adult minor and a minor's parent with oral and written notification of the requirements of this section in a language and format that the minor and parent understand. The center must obtain the signature of the adult minor and minor's parent to confirm that the individual received the notice.

(1) ensure that a minor is free from abuse, neglect, and exploitation at the center, as described in §550.903 [~~§15.903~~] of this division (relating to Abuse, Neglect, or Exploitation Reportable to HHSC [~~DADS~~]);

(2) inform the [a] minor and a minor's parent of the center's policy for reporting abuse, neglect, or exploitation of a minor;

(3) ensure that the [a] minor and the minor's property is treated with respect;

(4) at the time of admission, inform the [an] adult minor or the [~~and a~~] minor's parent, orally and in a written statement, that a complaint or question about the center may be directed to the HHSC Complaint and Incident Intake Section [~~Department of Aging and Disability Services, DADS Consumer Rights and Services Division~~], P.O. Box 149030, Austin, Texas 78714-9030, toll free 1-800-458-9858, or through the online portal;

(5) at the time of admission, inform the [an] adult minor or the [~~and a~~] minor's parent, orally and in a written statement, that:

(A) states that complaints about services at the center may be directed to the administrator who will address them promptly;

(B) provides the time frame in which a center must review and resolve the complaint as described in §550.904 [~~§15.904~~] of this division (relating to Investigations of a Complaint and Grievance); and

(C) does not include a statement that a complaint must be made to the center administrator before directing a complaint to HHSC [~~DADS~~];

(6) ensure that the [a] minor is not subjected to unlawful discrimination or retaliation;

(7) ensure that the [a] minor is treated appropriate to the minor's [~~his or her~~] age and developmental status;

(8) ensure that the [a] minor is allowed to interact with other minors, including through planned and spontaneous active play, respective to a minor's condition and physician orders;

(9) ensure that the [an] adult minor or the [~~and a~~] minor's parent are informed in advance about the services to be provided, including:

(A) staff who will provide the services and the proposed frequency of each service; and

(B) any change in the plan of care before the change is made, except when a delay based on notification would compromise the health and safety of the [a] minor;

(10) ensure that the [an] adult minor or the [~~and a~~] minor's parent are informed of the expected outcomes of services and any specific limitations or barriers to services;

(11) ensure that the [an] adult minor or the [~~and a~~] minor's parent are allowed and encouraged to participate in planning services and in planning changes to services and that the adult minor or [~~and~~] the minor's parent consented to the changes before the changes are made, except when a delay based on participation in planning or obtaining consent would compromise the immediate health and safety of the [a] minor;

(12) ensure that the [an] adult minor or the [~~and a~~] minor's parent are informed of the center's policies on implementing an advance directive in accordance with §550.902 [~~§15.902~~] of this division (relating to Advance Directives) and to receive information about executing an advance directive;

(13) ensure that the [an] adult minor or the [~~and a~~] minor's parent are allowed to refuse services;

(14) ensure that the minor's medical record is kept confidential and the [an] adult minor or the [~~and a~~] minor's parent are informed of the center's policies and procedures regarding disclosure of medical records;

(15) ensure that the [an] adult minor or the [~~and a~~] minor's parent are informed, before care is provided, of the:

(A) extent to which payment for the center's services may be expected from Medicaid, or any other federally funded or aided program known to the center, or any other third-party payment source;

(B) charges for services not covered by a third-party payment source; and

(16) inform the [an] adult minor or the [~~and a~~] minor's parent of any changes in the information provided in accordance with paragraph (15) of this subsection as soon as possible after changes occur, but no later than 30 days after the date the center becomes aware of the change;

(17) inform the [an] adult minor or the [~~and a~~] minor's parent of the availability of other programs, including day care, early intervention programs, or school; and

(18) ensure that the [an] adult minor or the [~~and a~~] minor's parent are allowed to convene or participate in a council or support group for individuals receiving services at the center.

§550.902.Advance Directives.

(a) A center must adopt and enforce a written policy regarding implementation of advance directives. The policy must be in compliance with the Advance Directives Act, THSC, Chapter 166. The policy must include a clear and precise statement of any procedure the center is unwilling or unable to provide or withhold in accordance with an advance directive.

(b) A center must provide written notice to a minor's parent or an [~~the~~] adult minor of the written policy required by subsection (a) of this section. The notice must be provided at the earlier of:

(1) the time the [a] minor is admitted to receive services at the center; or

(2) the time service provision begins for the [a] minor.

§550.903.Abuse, Neglect, or Exploitation Reportable to HHSC [~~DADS~~].

(a) The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.

(1) Abuse, neglect, and exploitation of a minor have the meanings assigned in THSC Chapter 260A. [~~; and~~]

(2) Employee means an individual directly employed by a center, a contractor, or a volunteer.

(b) HHSC [~~DADS~~] investigates a complaint or an incident of abuse, neglect, or exploitation when the act occurs at a center, a center employee is responsible for the care of the [a] minor at the time the act occurs, or the alleged perpetrator is associated with the center. A complaint of abuse, neglect, or exploitation that does not meet these criteria must be referred to the Department of Family and Protective Services.

(c) A center must adopt and enforce a written policy relating to the center's procedures for preventing, detecting, and reporting alleged acts of abuse, neglect, and exploitation of a minor.

(d) A center's employee who has cause to believe that the physical or mental health or welfare of a minor has been or may be adversely affected by abuse, neglect, or exploitation must report the information immediately:

(1) to the HHSC Complaint and Incident Intake Section [~~DADS Consumer Rights and Services section~~] at 1-800-458-9858, ciicomplaints@hhs.texas.gov, or via the online portal [~~DADS website~~];

(2) to one of the following law enforcement agencies in accordance with THSC Chapter 260A:

(A) a municipal law enforcement agency, if the center is located in the territorial boundaries of a municipality; or

(B) the sheriff's department of the county in which the center is located if a center is not located in the territorial boundaries of a municipality; and

(3) in accordance with Texas Family Code, §261.101.

(e) The following information must be reported to HHSC [~~DADS~~]:

(1) name, age, and address of the alleged victim;

(2) name and address of the person responsible for the care of the alleged victim;

(3) nature of the alleged act;

(4) nature and extent of the alleged victim's condition;

(5) identity of the alleged perpetrator; and

(6) any other relevant information.

(f) A center must investigate allegations of abuse, neglect, or exploitation immediately and send a written report of the investigation using the HHSC [~~DADS~~] Provider Investigation Report form to the HHSC [~~DADS~~] Complaint Intake Unit no later than five days after the initial report.

(g) A center must complete the HHSC [~~DADS~~] Provider Investigation Report form and include the following information:

(1) incident date;

(2) the alleged victim;

(3) the alleged perpetrator;

(4) any witnesses;

(5) the allegation;

(6) any injury or adverse effect;

(7) any assessments made;

(8) any treatment required;

(9) the investigation summary; and

(10) any action taken.

(h) A center must require an employee, as a condition of employment with a center, to sign a statement indicating that the employee may be criminally liable for the failure to report abuse, neglect, or exploitation.

(i) A center must prominently and conspicuously post a readable sign for display in a public area accessible to minors, minors' parents, employees, and visitors that reads: "Cases of Suspected Abuse, Neglect, or Exploitation Shall be Reported to HHSC [~~the Department of Aging and Disability Services~~] by calling 1-800-458-9858."

§550.904.Investigations of a Complaint and Grievance.

(a) HHSC [~~DADS~~] investigates a complaint of non-compliance with THSC Chapter 248A or this chapter regarding:

(1) treatment or care that was furnished at a center;

(2) treatment or care that a center failed to furnish; or

(3) a lack of respect for a minor's property by anyone furnishing services at the center.

(b) A center must adopt and enforce a written policy relating to the center's procedures for prompt investigation of complaints, grievances, and reports of abuse, neglect, and exploitation.

(1) acknowledge receipt of a complaint or grievance;

(2) document receipt of a complaint or grievance;

(3) initiate an investigation no later than 10 days after a center receives a complaint or grievance; and

(4) document all components of an investigation.

(d) A center must retain all investigation documentation for a minimum of three years from the date a complaint or grievance was received.

(e) A center must not retaliate against a person for filing a complaint, presenting a grievance, or providing in good faith information relating to services provided by a center.

(1) A center may not retaliate against a minor or a minor's parent for filing a complaint, presenting a grievance, or providing, in good faith, information relating to services provided at the center.

(2) A center is not prohibited from terminating an employee for a reason other than retaliation.

(f) A center must not discharge or otherwise retaliate against a minor or a minor's parent for presenting a complaint or grievance against a center.

§550.905.Reporting of a Minor's Death.

(a) A center must report to HHSC [~~DADS~~] the death of a minor at the center and those minors transferred from the center to a hospital who expire within 24 hours after the transfer.

(b) A center must submit to the HHSC Complaint and Incident Intake Section an HHSC [~~DADS Consumer Rights and Services section a DADS~~] Provider Investigation Incident Report form no later than 10 days after the date a minor dies. A center must complete the HHSC [~~DADS~~] Provider Investigation Incident Report form and include the following information:

(1) name of a deceased minor;

(2) social security number of a deceased minor;

(3) date, time, place of death; and

(4) name and address of a center.

§550.906.Examination of Inspection Results.

(a) A center must make available to any person on request a copy of each HHSC [~~DADS~~] written notification of the inspection results pertaining to the center.

(b) Before making the inspection results available under this subsection, the center must redact from the report any information that is confidential under other state or federal law.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402403

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

DIVISION 9. MEDICAL RECORDS, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT, DISSOLUTION AND RETENTION OF RECORDS

26 TAC §§550.1001 - 550.1003

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1001.Medical Records.

(a) In accordance with accepted principles of practice, a center must establish and maintain a medical record system to ensure that the services provided to a minor are completely and accurately documented, readily accessible, and systematically organized to facilitate the compilation and retrieval of information.

(b) A center must establish a medical record for a minor and must maintain the record in accordance with and contain the information described in subsection (g) of this section.

(d) A center must adopt and enforce written procedures regarding the use and removal of records, the release of information, and when applicable, the incorporation of clinical, progress, or other notes into the medical record.

(e) A center may not release any portion of a minor's medical record to anyone other than the [an] adult minor or the [~~and a~~] minor's parent, except as allowed by law.

(f) A center must establish a secure area for original active medical record storage at the center's place of business.

(1) A center must ensure that a minor's medical record is treated as confidential, safeguarded against loss and unofficial use, and maintained according to professional standards of practice.

(2) A center must keep a minor's medical record in original form, as a microfilmed copy, on an electronic system, or as a certified copy.

(3) A medical record in its original form is a signed paper record or an electronically signed computer record.

(4) A center must ensure that electronic [~~computerized~~] medical records meet the requirements of paper records, including protection from unofficial use as specified in subsection (f)(1) [~~(g)~~] of this section [~~and retention for the period specified in §15.1004 of this division (relating to Retention of Records)~~].

(5) A center must ensure that an entry to a medical record regarding the delivery of services is not altered without evidence and explanation of the alteration.

(6) A center must ensure that an entry to a minor's medical record is current, accurate, legible, clear, complete, and appropriately authenticated and dated with the date of entry by the individual making the entry. The record must document all services provided on behalf of the center. The center must not use correction fluid or tape in the record. The center must make corrections by striking through the error with a single line and including the date the correction was made and the initials of the person making the correction.

(7) A center must store the record of an inactive minor's medical record on paper, microfilm, or electronically. The center must secure the medical record and ensure that it is readily retrievable by the center staff.

(g) Each medical record must include the following information as applicable to the services provided on behalf of a center:

(1) a minor's referral and application for services including, but not limited to:

(A) the [a] minor's full name;

(B) the minor's sex and date of birth;

(C) the name, address, and telephone number of the [a] minor's parent, or others as identified by the [a] minor's parent;

(D) the [a] minor's prescribing physician's name and telephone numbers, and an emergency contact number; and

(E) the [a] minor's prescribing physician's initial order for services;

(2) comprehensive assessments, pertinent medical history including allergies and special precautions, and subsequent assessments;

(3) plans of care, nursing care plans, and other plans as applicable;

(4) verbal orders of a physician reduced to writing and signed by the physician in accordance with the center's policy as required by §550.702 [~~§15.702~~] of this subchapter (relating to Receiving Physician Orders);

(5) documentation of nutritional counseling and special diets, as appropriate;

(6) clinical and progress notes from all professionals providing services to the [a] minor;

(7) documentation of all known services and significant events;

(8) current medication list;

(9) medication administration record, if medication is administered by center staff;

(10) current immunization record;

(11) written acknowledgment of the [an] adult minor's or the [~~and a~~] minor's parent's receipt of written notification of the requirements of §550.901 [~~§15.901~~] of this subchapter (relating to Rights and Responsibilities);

(12) written acknowledgment of the [an] adult minor's or the [~~and a~~] minor's parent's receipt of a center's policy relating to the reporting of abuse, neglect, or exploitation of a minor;

(13) written acknowledgement of the [an] adult minor's or the [~~and a~~] minor's parent's receipt of the notice of advance directives;

(14) written acknowledgement of the [an] adult minor's or the [~~and a~~] minor's parent's receipt of the center's policies relating to discipline and guidance;

(15) documentation demonstrating that the [an] adult minor or the [~~and a~~] minor's parent have been informed of how to register a complaint in accordance with §550.901 [~~§15.901~~] of this subchapter;

(16) discharge summary, including the reason for discharge or transfer and a center's documented notice to the [an] adult minor, the [a] minor's parent, the [a] minor's prescribing physician, and other individuals as required in §550.608 [~~§15.608~~] of this subchapter (relating to Discharge or Transfer Notification);

(17) services provided to the [a] minor's parent; and

(18) all consent and election forms, as applicable.

(h) A [~~The~~] center must ensure that clinical and progress notes are written the day service is rendered and incorporated into the medical record no later than two business days after the services are rendered.

(i) A center must ensure the retention of the medical record for a minor meets the requirements in §550.1004 of this division (relating to Retention of Records).

§550.1002.Quality Assessment and Performance Improvement.

(a) A center must develop, implement, and maintain a written quality assessment and performance improvement (QAPI) program.

(b) A center must designate in writing the group or individuals, by title, responsible for ensuring that a center's written QAPI program is developed, implemented, and maintained in accordance with this section.

(c) The center must implement the QAPI program using a QAPI Committee. The QAPI committee must be composed of the following persons based on the services provided at the center during the time period under review by the QAPI:

(1) the administrator;

(2) the medical director;

(3) the nursing director;

(4) a therapist from each therapy that provided services during the review period (e.g. [~~i.e.~~], if physical therapy was provided during the quarter being reviewed, a physical therapist [PT] must be on the QAPI committee);

(5) a social worker that provided services during the review period; and

(6) a supervisor of the direct care staff.

(d) The QAPI program must evaluate all services including:

(1) monitoring activities that have an impact on health and safety of minors;

(2) monitoring and evaluating the quality of services;

(3) improving measurable outcomes for minors, if applicable;

(4) resolving problems identified by a center and raised by parents and adult minors; and

(5) ensuring a center's compliance with THSC Chapter 248A and this chapter.

(e) The QAPI program must be ongoing. Ongoing means there is a continuous and periodic collection and assessment of measurable care provided to minors and administrative quality data.

(f) The written QAPI program must include the frequency and detail of data collection.

(g) A center must collect quality data at least quarterly for all services provided to a minor.

(h) The QAPI program must include a system that measures the quality, effectiveness, and safety of services provided to minors and identifies opportunities and priorities for performance improvement.

(i) The system of measures must allow the QAPI Committee to collect and analyze services provided to minors and administrative quality data. The measures must include a review and analysis of the following, as applicable to the services provided at the center and the problems a center identifies:

(1) a representative sample of active and closed medical records;

(2) negative care outcomes to minors or adverse events;

(3) complaints and grievances;

(4) self-reported incidents alleging abuse, neglect, or exploitation by the center employees, volunteers, or contractors;

(5) minor's parent satisfaction surveys;

(6) infection control activities;

(7) incident reports, including reports of medication errors and unprofessional conduct by licensed staff;

(8) the accuracy and completeness of center personnel records;

(9) the implementation and effectiveness of center policies;

(10) the effectiveness and safety of all services provided, including:

(A) competency and qualifications of staff;

(B) the promptness, safety, and quality of services provided to minors;

(D) a determination that services are provided as outlined in each minor's plan of care; and

(11) an annual review and evaluation of a center's total operation.

(j) The QAPI Committee must meet quarterly or more often if needed to analyze the data collected and to use the data to improve services. A center must immediately correct identified problems that directly or potentially threaten health and safety of minors. The QAPI Committee must:

(1) plan and document actions taken to correct identified problems, and if necessary, to revise center policies;

(2) measure and document the outcome of the corrective action taken; and

(3) monitor and document the level of improvement over time to ensure sustained improvements.

(k) The QAPI Committee must review and update or revise the written QAPI program at least annually, or more often if needed.

(l) The center must document the ongoing implementation and annual review of the written QAPI program.

(m) The center must keep QAPI documents confidential and make the documents readily available to HHSC [~~DADS~~] upon request.

§550.1003.Dissolution.

(a) A center must adopt and enforce a written policy that describes the center's written contingency plan for dissolution.

(b) A center must implement the dissolution plan in the event of dissolution to ensure continuity of a minor's care.

(1) notify each minor [~~minors~~] actively receiving services and the [a] minor's parent of a center's dissolution; and

(2) transfer or discharge minors actively receiving services consistent with §550.608 [~~§15.608~~] of this subchapter (relating to Discharge or Transfer Notification).

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402404

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER D. TRANSPORTATION

26 TAC §550.1101, §550.1102

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1101.Transportation Services.

(a) A center must ensure transportation services are provided for a minor, as authorized by an adult minor or [,] the minor's parent[,] and the minor's prescribing physician:

(1) from the minor's home to the center;

(2) from the center to the minor's home; and

(3) to and from the center for services coordinated by the center.

(b) A minor's parent is not required to accompany the minor when the center transports or provides for the transport of the minor.

(c) A center must ensure that vehicles are accessible for a minor with disabilities and equipped to meet the needs of a minor during transport.

(d) A minor's parent may decline a center's transportation services.

(e) A center must adopt and enforce written policies and procedures describing the staff and equipment that will accompany a minor during transportation. The staff must include a driver and a direct care staff member, or [~~and~~] a nurse, if necessary, depending on the acuity of the minors and as determined in coordination with the prescribing physician.

(f) A center must ensure that:

(1) a person transporting a minor on behalf of a center has a valid and appropriate Texas driver's license, a copy of which the center must keep on file;

(2) a vehicle used to transport a minor has a current Texas safety inspection sticker and vehicle registration decal properly affixed to a vehicle;

(3) the center maintains commercial insurance for the operation of a center's vehicles, including coverage for minors and staff in a center's vehicle in the event of accident or injury;

(4) documentation of the insurance is maintained and includes:

(A) the name of the insurance company;

(B) the insurance policy number;

(D) an explanation of the coverage;

(5) the center provides a driver and the center's staff riding in the vehicle [~~nurse~~] with an up-to-date master transportation list that includes a minor's name, pick up and drop off locations, and authorized persons to whom a minor may be released;

(6) the master transportation list is on file at the center;

(7) the driver and the center's staff [~~nurse~~ ] riding in the vehicle maintain a daily attendance record for each trip that includes the driver's name, the date, names of all passengers in the vehicle, the name of the person to whom a minor was released, and the time of release; and

(8) the number of people in a vehicle used to transport minors does not exceed the manufacturer's recommended capacity for the vehicle.

§550.1102.Transportation Safety Provisions.

(a) A center must adopt and enforce written policies and procedures to ensure the care and safety of minors during transport.

(b) A center must appropriately train staff on the needs of a minor being transported.

(c) A center must properly restrain or secure a minor when the minor is transported by the center in a motor vehicle, in accordance with applicable federal motor vehicle safety standards, state law, THSC [~~Texas Health and Safety Code (THSC)~~] Chapter 248A, and this chapter.

(d) A center must ensure that:

(1) a minor boards and leaves the vehicle from the curbside of the street and is safely accompanied to the minor's destination;

(2) there is a first aid kit with unexpired supplies, including oxygen, a pulse oximeter, and suction equipment in each center vehicle;

(3) the center prohibits the use of tobacco in any form, electronic cigarettes, alcohol, [~~and~~] possession of illegal substances or unauthorized potentially toxic substances, firearms, and pellet or BB guns, including loaded or unloaded BB guns, in any vehicle;

(4) the driver does not use a hand-held wireless communication device while operating a center vehicle;

(5) staff accompany a minor during transportation as described in §550.1101(e) of this subchapter (relating to Transportation Services) and paragraph (6) of this subsection;

~~[(5) a center's nurse accompanies minors, as necessary during transport, as determined by the minor's plan of care;]~~

(6) at least one direct care staff member, or more depending on the acuity of the minors, accompanies every seven minors;

(7) the driver or center's staff riding in the vehicle [~~nurse~~] does not leave a minor unattended in the vehicle at any time;

(8) the driver or the center's staff [~~nurse~~ ] riding in the vehicle inspects the vehicle at the completion of each trip to ensure that no minor is left in the vehicle; and

(9) the center maintains documentation that includes the signature of the individual conducting the inspection described in paragraph (8) of this subsection and the time of inspection.

(e) A center must post near the emergency exit of each vehicle that transports a minor the following information in an easily readable font:

(1) the name of the administrator;

(2) the center's name;

(3) the center's telephone number; and

(4) the center's address.

(f) The center must adopt and enforce a policy on emergencies while transporting a minor. The policy must include:

(1) procedures for mechanical break downs;

(2) procedures for vehicle accidents; and

(3) procedures for a minor's emergency.

(g) If a center conducts a field trip, the center must ensure that the driver or center's staff [~~nurse~~] riding in the vehicle [~~must~~] inspect the vehicle and account for each minor upon arrival and departure from each destination to ensure that no minor is left in the vehicle after reaching the vehicle's final destination.

(1) A center must ensure that the driver or center's staff [~~nurse~~] riding in the vehicle maintains a field trip record for each trip. The record must include the driver's name, the staff's [~~nurse's~~] name, the time and date, the vehicle's destinations, and names of all passengers in the vehicle.

(2) A center must maintain documentation that includes the signature of the person conducting the inspection and the time of each inspection during the field trip.

(3) Appropriate staff must be present when a minor is delivered to the center.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402405

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER E. BUILDING REQUIREMENTS

26 TAC §§550.1202 - 550.1204, 550.1206, 550.1207, 550.1211, 550.1215, 550.1217 - 550.1220, 550.1222, 550.1224

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1202.Plan Reviews.

(a) Plans for new buildings, additions, conversions of buildings not licensed by HHSC [~~DADS~~], and the remodeling of existing licensed facilities must be submitted to HHSC [~~DADS~~] for review. No later than 30 days after receipt of the plans, HHSC [~~DADS~~] informs an applicant in writing of the results of the review.

(b) If the submitted plans comply with HHSC [~~DADS~~] architectural requirements, HHSC [~~DADS~~] may not subsequently change the architectural requirement that applies to the project unless the change is required by federal law or an applicant fails to complete the project no later than two years after submitting the plans to HHSC [~~DADS~~].

(d) HHSC [~~DADS~~] may impose a deadline for completing a project using requirements that are revised after the project was reviewed.

(e) Submittal of plans.

(1) One copy of contract documents must be submitted to HHSC [~~DADS~~] before construction begins. The documents must:

(A) include working drawing and specifications;

(B) have sufficient detail for HHSC [~~DADS~~] to interpret compliance with this chapter and for a general contractor or builder to ensure proper construction; and

(C) be prepared according to accepted architectural practice and include general construction, special conditions, and schedules.

(2) Final copies of plans must be submitted to HHSC [~~DADS~~] and include:

(A) a title block that shows the name of the center;

(B) the person or organization preparing the sheet;

(D) the center's address; and

(E) the drawing date.

(3) Sheets and sections covering structural, electrical, mechanical, and sanitary engineering final plans, designs, and specifications must bear the seal of a professional engineer licensed by the Texas Board of Professional Engineers.

(4) The [~~An architect licensed by the Texas Board of Architectural Examiners must prepare~~] contract documents for additions, remodeling, and construction of a new center must be prepared by an architect licensed by the Texas Board of Architectural Examiners. Drawings must bear the seal of the architect.

(5) A final plan for a major addition to a center must be submitted to HHSC [~~DADS~~] and include a basic layout to scale of the entire building into which the addition will connect. North direction must be shown. The entire basic layout must be scaled to fit on a single 8 1/2-inch by 11-inch sheet.

(6) Final plans and specifications for conversions or remodeling must be submitted to HHSC [~~DADS~~] and include all parts and features involved.

(7) Qualified staff must be employed to prepare the contract documents for construction. If the contract documents have errors or omissions to the extent that compliance with this chapter cannot be reasonably ensured or determined, HHSC [~~DADS~~] may request a revised set of documents for review.

(8) HHSC [~~DADS~~] review of the plans and specifications is based on general utility and compliance with this chapter and the Life Safety Code. HHSC [~~DADS~~] review is not an all-inclusive review of the structural, electrical, or mechanical components of a center. HHSC [~~DADS~~] review does not include a review of building plans for compliance with the Texas Accessibility Standards as administered and enforced by the Texas Department of Licensing and Regulation.

(9) Plan review fees must be submitted in accordance with §550.113 [~~§15.113~~] of this chapter (relating to Plan Review Fees).

(f) Contract documents.

(1) Site plan documents must be submitted to HHSC [~~DADS~~] and include:

(A) grade contours;

(B) streets with names;

(D) fire hydrants;

(E) fire lanes;

(F) public or private utilities;

(G) fences; and

(H) unusual site conditions, including:

(i) ditches;

(ii) low water levels;

(iii) other buildings on-site; and

(iv) indications of buildings five feet or less beyond site property lines.

(2) Foundation plan documents must be submitted to HHSC [~~DADS~~] and include general foundation design and details.

(3) Floor plan documents must be submitted to HHSC [~~DADS~~] and include:

(A) room names, numbers, and usages;

(B) numbered doors, including swing;

(D) legend or clarification of wall types that include:

(i) dimensions;

(ii) fixed equipment;

(iii) plumbing fixtures;

(iv) basic layout of the food preparation area; and

(v) identification of all smoke barrier walls from outside wall to outside wall or fire walls.

(4) For both new construction and additions or remodeling to existing buildings, an overall plan of the entire building drawn or reduced to fit on a single 8 1/2-inch by 11-inch sheet must be submitted to HHSC [~~DADS~~].

(5) Schedules must be submitted to HHSC [~~DADS~~ ] and include:

(A) door materials, widths, and types;

(B) window materials, sizes, and types;

(D) special hardware.

(6) Elevations and roof plans must be submitted to HHSC [~~DADS~~]. Plans must include exterior elevations, including:

(A) material note indications;

(B) rooftop equipment;

(D) drains;

(E) gas piping; and

(F) interior elevations where needed for special conditions.

(7) Contract document details must be submitted to HHSC [~~DADS~~] and include:

(A) wall sections as needed, especially for special conditions;

(B) cabinet and built-in work, basic design only;

(D) miscellaneous details and enlargements as needed.

(8) Building structure documents must be submitted to HHSC [~~DADS~~] and include:

(A) structural framing layout and details used primarily for column, beam, joist, and structural building;

(B) roof framing layout if it cannot be adequately shown on a cross section; and

(C) cross sections in quantity and detail to show sufficient structural design and structural details as necessary to ensure adequate structural design and calculated design loads.

(9) Electrical documents must be submitted to HHSC [~~DADS~~] and include:

(A) electrical layout, including lights, convenience outlets, equipment outlets, switches, and other electrical outlets and devices;

(B) service, circuiting, distribution, and panel diagrams;

(D) emergency electrical provisions, including generators and panels;

(E) staff communication systems;

(F) fire alarm and similar systems, including control panel, devices, and alarms; and

(G) sizes and details sufficient to ensure safe and properly operating systems.

(10) Plumbing documents must be submitted to HHSC [~~DADS~~] and include:

(A) plumbing layout with pipe sizes and details sufficient to ensure safe and properly operating systems;

(B) water systems;

(D) gas systems; and

(E) other systems normally considered under the scope of plumbing, fixtures, and provisions for combustion air supply.

(11) Heating, ventilation [~~ventilating~~], and air-conditioning (HVAC) systems [~~(HVAC)~~] documents must be submitted to HHSC [~~DADS~~] and include:

(A) sufficient details of HVAC systems and components to ensure a safe and properly operating installation, including heating, ventilation [~~ventilating~~], and air-conditioning layout, ducts, protection of duct inlets and outlets, combustion air, piping, exhausts, and duct smoke and fire dampers; and

(B) equipment types, sizes, and locations.

(12) Sprinkler system documents must be submitted to HHSC [~~DADS~~] and include:

(A) plans and details of National Fire Protection Association (NFPA) designed systems to meet the requirements of NFPA 13, Standard for the Installation of Sprinklers;

(B) plans and details of partial systems provided only for hazardous areas; and

(13) Specifications must be submitted to HHSC [~~DADS~~] that include:

(A) installation techniques;

(B) quality standards and manufacturers;

(D) design criteria;

(E) special equipment;

(F) hardware;

(G) finishes; and

(H) other specifications as needed to amplify drawings and notes.

(14) Other layouts, plans or details must be submitted to HHSC [~~DADS~~] as necessary for HHSC [~~DADS~~] to obtain a clear understanding of the design and scope of the project. Plans covering private water or sewer systems that have been reviewed by the health or wastewater authority having appropriate jurisdiction must be submitted to HHSC [~~DADS~~].

(g) Construction phase.

(1) The HHSC [~~DADS~~] Architectural Unit must be notified in writing before beginning construction of a new center or the remodeling of an existing center.

(2) HHSC [~~DADS~~] requires additional drawings if construction of the center is not performed in accordance with the completed plans and specifications as submitted to HHSC [~~DADS~~] for review or as modified in accordance with HHSC [~~DADS~~] review requirements, if the change is significant.

(h) Initial inspection of completed construction.

(1) After completion of construction, including grounds and basic equipment and furnishings, HHSC [~~DADS~~] performs an initial architectural inspection of the center before the center admits a minor. HHSC [~~DADS~~] schedules an initial architectural inspection after HHSC [~~DADS~~] receives a licensure application, required fees, fire marshal approval, approval of local building authority, and a letter from an architect or engineer stating that, to the best of the architect or engineer's knowledge, the center meets the building requirements for licensure.

(2) If HHSC [~~DADS~~] Life Safety Code staff inspect the completed construction and find it in compliance with this chapter, the HHSC [~~DADS~~] Architectural Unit forwards the information to the HHSC [~~DADS~~] Licensing and Credentialing Unit as part of an applicant's license application. For additions to or remodeling of an existing center, HHSC [~~DADS~~] may require an applicant to submit a revision or modification to an existing license. The building, including basic furnishings and operational needs, grades, drives, and parking, must be 100 percent complete at the time of the HHSC [~~DADS~~] initial architectural inspection. A center may admit at least one but no more than three minors after it receives initial approval from HHSC [~~DADS~~] but before a license is issued.

(3) An applicant must make the following documents related to the completed building available to the HHSC [~~DADS~~] architectural inspection surveyor at the time of the inspection:

(A) written approval of the local authorities as required in paragraph (1) of this subsection;

(B) for fire detection and alarm systems:

(i) record drawings of the fire detection and alarm system as installed, signed by an alarm planning superintendent licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer;

(ii) a sequence of operation, the owner's manuals and the manufacturer's published instructions covering all system equipment;

(iii) a signed copy of the State Fire Marshal's Office Fire Alarm Installation Certificate; and

(iv) for software-based systems, a record copy of the site-specific software, excluding the system executive software or external programmer software in non-volatile, non-erasable, non-rewritable memory;

(C) documentation of materials used in the building that are required to have a specific limited fire or flame spread rating, including special wall finishes or floor coverings, flame retardant rated ceilings and curtains, including cubicle curtains; [.]

(D) for carpeting that is required to have a specific limited fire or flame spread rating, a signed letter from the installer verifying that the carpeting installed is named in the laboratory test document; and

(E) for fire sprinkler systems:

(i) record drawings of the fire sprinkler system as installed, signed by a responsible managing employee, licensed by the State Fire Marshal's Office or sealed by a licensed professional engineer;

(ii) the hydraulic calculations;

(iii) the alarm configuration;

(iv) above ground and underground Contractor's Material and Test Certificate;

(v) the literature and instructions provided by the manufacturer describing the proper operation and maintenance of all equipment and devices in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems;

(vi) service contracts for maintenance and testing of alarm systems and sprinkler systems;

(vii) a copy of gas test results of the center's gas lines from the meter;

(viii) a written statement from an architect or engineer stating, to the best of the architect or engineer's knowledge, the building was constructed in substantial compliance with the construction documents, the Life Safety Code, this chapter, and local codes; and

(ix) any other such documentation as needed.

(i) Non-approval of new construction.

(1) If, during the initial on-site architectural inspection of completed construction, the HHSC [~~DADS~~] Life Safety Code surveyor finds certain basic requirements are not met, the surveyor may recommend that the center not be licensed or approved for occupancy. Items that may result in this recommendation include:

(A) substantial changes made during construction that were not submitted to HHSC [~~DADS~~] for review and that may require revised "as-built" drawings to include the changes, including[.] architectural, structural, mechanical, and electrical items as specified in this section;

(B) construction that does not meet minimum code or licensure standards, including corridors that are less than the required width, ceilings installed at less than the minimum seven-foot, six-inch height, and other features that would disrupt or otherwise adversely affect minors and staff if corrected after occupancy;

(D) fire protection systems, including fire alarm systems, emergency power and lighting, and sprinkler systems, that are not completely installed or functioning properly;

(E) required exits that not all usable according to NFPA 101 requirements;

(F) telephones that are not installed or not working properly;

(G) sufficient basic furnishings, essential appliances, and equipment that are not installed or functioning; and

(H) other basic operational or safety feature that would preclude safe and normal occupancy by a minor on that day.

(2) An applicant must submit copies of reduced-size floor plans on an 8 1/2-inch by 11-inch sheet, in duplicate, to HHSC [~~DADS~~] for records and for the center's use for an evacuation plan, or fire alarm zone identification. The plan must contain basic legible information including scale, room usage names, actual bedroom numbers, doors, windows, and any other pertinent information.

§550.1203.Design Criteria.

(a) A center must be designed in accordance with:

(1) the Health Care Occupancy chapter of the 2000 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code for newly constructed centers or centers converting an existing unlicensed building to a center; and

(2) the requirements of Limited Care, as defined by NFPA 101.

(b) An applicant for a center license must submit to HHSC [~~DADS~~] site approval by the local building department and fire marshal having appropriate jurisdiction.

(c) An applicant for a center license must meet applicable local, state, or national codes and ordinances as determined by the authority having appropriate jurisdiction for those codes and ordinances and by HHSC [~~DADS~~].

(d) A center must meet the requirements of the International Plumbing Code or Uniform Plumbing Code, as adopted by the local municipality.

(e) If conflicting codes apply to the construction of the center, the more stringent codes apply.

(f) A center may not be built in an area designated as a floodplain of 100 years or less.

(g) A center must comply with the accessibility requirements for individuals with disabilities as referenced in the revised regulations for Title II and III (2010 ADA Standards for Accessible Design) of the Americans with Disabilities Act of 1990 at Title 42, United States Code, Chapter 126; federal regulations at 28 Code of Federal Regulations [~~Title 28,~~] Code of Federal Regulations, Part 35 and Part 36; Texas Accessibility Standards at Texas Government Code, Chapter 469; and Texas Department of Licensing and Regulation rules at 16 Texas Administrative Code [~~TAC~~] Chapter 68 (relating to Elimination of Architectural Barriers).

§550.1204.Fire Safety.

(a) A center's construction type is limited to the building construction shown in the minimum construction requirements in the Life Safety Code chapter for New Health Care Occupancies.

(b) A center must have a National Fire Protection Association (NFPA) 72 fire alarm system with initiation, notification, emergency forces notification, annunciation, emergency control and detection in accordance with the Life Safety Code. The center must have a written contract with a fire alarm firm that has been issued an Alarm Certificate of Registration number from the Texas State Fire Marshal's Office to inspect, test and maintain a fire alarm system to meet NFPA 72 requirements, semiannually. Inspections required in the contract must be performed. The person performing the semiannual service must have an individual fire alarm license from the Texas State Fire Marshal's Office.

(c) A center must be protected throughout by an approved, supervised automatic sprinkler system installed in accordance with NFPA 13. The center must ensure that the sprinkler system is inspected, tested, and maintained in accordance with NFPA 25. The center must have a written contract with a fire protection sprinkler firm that has been issued a Sprinkler Certificate of Registration number from the Texas State Fire Marshal's Office to perform the required services, semiannually. The center must document and show to HHSC [~~DADS~~] that all the requirements of NFPA 25 are met including the annual inspection, test, and maintenance performed by the registered fire sprinkler firm. The center must retain one set of the fire sprinkler system plans and hydraulic calculations on the property.

(d) A center must distribute portable fire extinguishers throughout the center of size and type in accordance with NFPA 10.

(e) A center must provide emergency power for emergency lighting, exit signs, and the fire alarm by a generator.

(f) A center must ensure that the design, installation, and maintenance of emergency motor generators are in accordance with NFPA 37, NFPA 99, and NFPA 110.

(g) A center must ensure that the generator is of sufficient size to maintain Life Safety Code requirements, medical equipment, and heating, ventilation, and air-conditioning systems [~~HVAC~~ ] to operate in designated core areas of the center in the event of power failure.

(h) The center must ensure that emergency powered receptacles are used:

(1) for a patient care-related electrical appliance, including a biological refrigerator;

(2) at a nurse station; and

(3) in a medication room.

(i) The center must store and administer oxygen in accordance with NFPA 99.

§550.1206.Exterior Spaces.

(a) A center must have separate entrances for guests and minors.

(b) A center must have a covered entry with a covered drop-off for family, emergency medical services (EMS), and the center's vehicles.

(c) A center's roof overhang or canopy must extend as far as practicable to the face of the driveway or curb of the passenger access door of a passenger vehicle.

(d) A center's roof overhang or cover must be of sufficient height to allow entry or departure from EMS vehicles.

(e) A center must provide for an outdoor play space with a direct exit from the center into the outdoor play space. The outdoor play space should at least be 400 square feet in area with at least 20 percent of that area shaded.

(f) A center's play yard must meet the requirements of the Texas Accessibility Standards.

(g) A center must ensure that its structures and the grounds of the center that are used by minors are maintained in good repair and are free from hazards to health and safety.

(h) A center must fence or ensure natural barriers are present to protect a minor from areas determined to be unsafe by HHSC [~~DADS~~], including steep grades, cliffs, open pits, swimming pools, high voltage boosters, high voltage equipment, and high speed roads.

(i) A center must keep fences in good repair.

(j) A center must store garbage, rubbish, and trash securely in outdoor, covered containers.

(k) A center must keep trash collection receptacles and incinerators separated from outdoor recreational spaces and locate the receptacles and incinerators in a place to avoid being a nuisance.

§550.1207.Interior Spaces.

(a) A center must consist of a building suitable for the purpose intended, and have a minimum of 50 square feet of space per minor exclusive of kitchen, toilet facilities, storage areas, hallways, stairways, basements, and attics.

(b) If a center uses a room exclusively for dining or sleeping, the center must not count that space as part of the licensed capacity.

(c) A center must have sufficient rooms to accommodate and segregate the different age groups of minors being served at the center.

(d) A center must provide staff area and staff toilets.

(e) A center must provide a reception area.

(f) A center must provide an administrative office.

(g) A center must provide quiet rooms based on the needs of minors.

(h) A center's quiet room must contain a minimum of 100 square feet.

(i) A center must provide indoor recreational exercise play area.

(j) A center must provide a treatment room with a medication preparation area. The medication preparation area must contain a work counter, refrigerator, sink with hot and cold water, and locked storage for biologicals and drugs.

(k) A center must develop isolation procedures to prevent cross-infection and provide an isolation room with at least one large glass area for observation of a minor in accordance with §550.211 [~~§15.211~~] of this chapter (relating to Infection Prevention and Control Program and Vaccination Requirements). The isolation room must contain a minimum of 100 square feet.

(l) The center must make privacy accommodations available to attend to the personal care needs of a minor.

§550.1211.Linen Storage.

(a) A center must have a mechanical forced air exhaust system to the outside for soiled linen areas in accordance with §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

(b) A center must have separate storage areas for clean and soiled linen in accordance with §550.210 [~~§15.210~~ ] of this chapter.

§550.1215.Garbage.

(a) A center must store garbage, rubbish, and trash in an area separate from the areas used for the preparation and storage of food. A center must remove garbage, trash, and rubbish from the premises and sanitize the containers regularly.

(b) A center must meet the sanitation requirements in §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

§550.1217.Laundry.

(a) A center must have a supply of clean linen sufficient to meet the needs of a minor. Clean laundry must be provided by:

(1) an in-house laundry service;

(2) contract with another health care center; or

(3) an outside commercial laundry service.

(b) A center must handle, store, process, and transport laundry in a manner to prevent the spread of infection in accordance with §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

§550.1218.Housekeeping.

(a) A center must:

(1) maintain a clean and safe environment;[.]

(2) be free of unpleasant odors; and

(3) eliminate odors at the center at their source by prompt and thorough cleaning of commodes, urinals, bedpans, and other sources.

(b) A center must meet the housekeeping requirements in §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

§550.1219.Maintenance.

(a) A center must:

(1) ensure that the grounds and the exterior of the building, including the sidewalks, steps, porches, ramps, and fences are in good repair;

(2) keep equipment supplied by the center for a minor's needs in good repair, including wheelchairs, cribs, and mattresses;

(3) keep the interior of the building including walls, ceilings, floors, windows, window coverings, doors, plumbing, and electrical fixtures in good repair; and

(4) use pest control services provided by a licensed structural pest control applicator with a license category for pests.

(b) A center must meet the requirements in §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

§550.1220.Heating, Ventilation, and Air Conditioning Systems [~~(HVAC)~~].

(a) A center must use a safe heating, ventilation, and air conditioning (HVAC) [~~HVAC~~] system that meets the requirements of the National Fire Protection Association (NFPA) 90A and is sufficient to maintain a comfortable temperature, with a minimum of 65 degrees and a maximum of 80 degrees Fahrenheit, in all public and private areas year round.

(b) A center must ensure that during warm weather conditions, the temperature within the center does not exceed 80 degrees Fahrenheit. The center must ensure that the HVAC system operates in designated core areas of the center in the event of power failure.

(d) A center must inspect gas-fired heating equipment before the cold weather season to ensure that the equipment operates properly and safely. The center must ensure that gas-fired heating equipment is inspected by a person licensed or approved by the State of Texas to inspect the equipment.

(e) The center must maintain a record of the inspection conducted in accordance with subsection (d) of this section.

(f) A center must correct any unsatisfactory condition or evacuate or relocate the minors.

(g) A center must ensure that a gas heating unit and water heater are vented in accordance with NFPA 54 to carry the products of combustion to the outside atmosphere. The center must ensure that a vent is constructed and maintained to provide a continuous draft to the outside atmosphere in accordance with NFPA 54. The center must ensure that a heating unit is provided with a sufficient supply of outside combustion air in accordance with NFPA 54. A center must not use a portable heater within the center.

§550.1222.Sewage.

A center must ensure that sewage is disposed of by a public system or an approved sewage disposal system constructed and operated to conform with the standards established for systems by the Texas Commission on Environmental Quality and in accordance with sanitation requirements in §550.210 [~~§15.210~~] of this chapter (relating to Sanitation, Housekeeping, and Linens).

§550.1224.Waivers.

(a) HHSC [~~DADS~~] may grant a waiver for certain provisions of the physical plant and environment requirements of HHSC [~~DADS~~] licensure standards, which, in HHSC [~~DADS~~] opinion, would be impractical for a center to meet. In granting the waiver, HHSC [~~DADS~~], on a case by case basis, determines if:

(1) there are adverse effects on the health and safety of a minor if the center does not meet the licensure requirement; and

(2) the center will experience an unreasonable hardship if the requirement is not waived.

(b) HHSC [~~DADS~~] may require a center to offset or comply with an equivalent provision if HHSC [~~DADS~~] grants a waiver. A center must demonstrate an equivalent safety feature by utilizing the National Fire Protection Association 101A, Guide on Alternative Approaches to Life Safety, for waivers of the Life Safety Code.

(c) An HHSC [~~A DADS~~] waiver is not transferable in a change of ownership and is subject to HHSC [~~DADS~~] review or revocation upon any change in circumstances at the center.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402406

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER F. INSPECTIONS AND VISITS

26 TAC §§550.1301 - 550.1305

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1301.Inspections and Visits.

(a) HHSC [~~DADS~~] performs inspections, follow-up visits, compliance investigations, investigations of abuse, neglect and exploitation, and other contact visits at a center as deemed appropriate or as required to determine a center's compliance with this chapter.

(b) An inspection may be conducted by an inspector or by a team depending on the purpose of the inspection, size of a center, and other factors.

(d) HHSC [~~DADS~~] conducts at least one unannounced licensing inspection annually after issuance of a license.

(e) HHSC [~~DADS~~] may visit a center for purposes other than the reasons described in subsection (a) of this section.

(1) HHSC [~~DADS~~] may visit a center to consult with a center's staff to determine how a center's physical space may be expanded or upgraded or determine the progress of a center's construction or repairs, equipment installation or repairs, systems installation or repairs, or when conditions or emergencies arise, including fire, windstorm, or malfunctioning or nonfunctioning of electrical or mechanical systems.

(2) HHSC [~~DADS~~] may announce visits that are not for a purpose described in subsection (a) of this section.

§550.1302.Investigation of Complaints and Self-Reported Incidents.

(a) HHSC [~~DADS~~] investigates complaints of abuse, neglect, or exploitation if:

(1) the act occurs at the center;

(2) the center is responsible for the supervision of a minor at the time the act occurs;

(3) the alleged perpetrator is associated with the center; or

(4) the alleged perpetrator is present at the center.

(b) HHSC [~~DADS~~] refers complaints of abuse, neglect, or exploitation not meeting the criteria in subsection (a) of this section to the Department of Family and Protective Services.

(d) A center's investigation of complaints and self-reported incidents does not preclude HHSC [~~DADS~~] from taking action in accordance with Subchapter G of this chapter (relating to Enforcement).

(e) HHSC [~~DADS~~] notifies the following individuals of the results of an HHSC [~~a DADS~~] investigation:

(1) the individual who reported the allegation or complaint;

(2) an adult minor;

(3) a minor's parent;

(4) any person designated by an adult minor or minor's parent to receive information concerning a minor; and

(5) a center.

§550.1303.Cooperation with an Inspection and Visit.

(a) By applying for and holding a license, a license holder consents to entry or inspection of the center's premises by an HHSC [~~a DADS~~] representative to verify compliance with THSC Chapter 248A and this chapter.

(b) A center must make all of its books, records, and other documents maintained by or on behalf of a center accessible to HHSC [~~DADS~~] upon request.

(1) HHSC [~~DADS~~] is authorized to photocopy documents, photograph minors, and use any other available recording devices to preserve all relevant evidence of conditions found during an inspection or investigation that HHSC [~~DADS~~ ] reasonably believes threaten the health and safety of a minor.

(2) HHSC [~~DADS~~] may request, photocopy, and otherwise reproduce records and documents including admission sheets, medication records, observation notes, medical records, clinical notes, and any other of a center's documents.

(3) HHSC [~~DADS~~] protects the copies for privacy and confidentially purposes in accordance with recognized standards of medical records practice, applicable state laws, and HHSC [~~DADS~~] policy.

(1) make a false statement that a person knows or should know is false of a material fact about a matter under investigation by HHSC [~~DADS~~];

(2) willfully interfere with the work of an HHSC [~~a DADS~~] representative;

(3) willfully interfere with an HHSC [~~a DADS~~] representative in preserving evidence of a violation; or

(4) refuse to allow an HHSC [~~a DADS~~] representative to inspect a book, record, or file required to be maintained by or on behalf of a center.

(d) HHSC [~~DADS~~] may assess an administrative penalty for a violation of provisions in this section, or may take other enforcement action to deny, revoke, or suspend a license, if a center does not cooperate with an inspection.

(e) In order to preserve the integrity of the inspection and investigation process, a center must:

(1) not record, listen to, or eavesdrop on any HHSC interview with center staff or minors that the center staff knows HHSC intends to keep confidential, as evidenced by HHSC taking reasonable measures to prevent from being overheard; or

(2) not record, listen to, or eavesdrop on any HHSC internal discussions outside the presence of center staff when HHSC has requested a private room or office or distanced themselves from center staff, unless the center obtains HHSC written approval before beginning to record or listen to the discussion.

(f) A center must inform HHSC when security cameras or other existing recording devices in the center are in operation during any internal discussion by or among HHSC staff.

(g) When HHSC permits center staff by words or actions to be present, an interview or conversation for which center staff are present does not constitute a violation of this rule.

(h) This section does not prohibit a minor or a minor's parents from recording an HHSC interview with the minor.

§550.1304.Staff Requirements for an Inspection.

(a) The center's administrator, alternate administrator, nursing director, or alternate nursing director must be present in person at the entrance and exit conferences of every HHSC [~~DADS~~] inspection or visit and be available in person during the inspection.

(b) If a required individual is not at the center when the inspector arrives and is unavailable during the inspection, the inspector will make reasonable attempts to contact the individual.

(c) If an inspector arrives during regular business hours and the center is closed, an administrator, alternate administrator, nursing director, or alternate nursing director must provide the inspector entry to the center no later than two hours after the inspector's arrival at the center. The center must comply with the notice requirements described in §550.201 [~~§15.201~~] of this chapter (relating to Operating Hours).

§550.1305.General Provisions.

(a) HHSC [~~DADS~~] determines if a center meets the requirements of [~~the~~] THSC Chapter 248A and this chapter.

(b) After an inspection is completed, the inspector holds an exit conference to inform a center of the preliminary findings.

(c) A center may submit additional written documentation and facts after the exit conference only if the [a] center describes the additional documentation and facts to the inspector during the exit conference.

(1) A center must submit the additional written documentation and facts to the HHSC [~~DADS~~] inspector or inspection team no later than two business days after the end of the exit conference.

(2) If a center properly submits additional written documentation, the inspector may add the documentation to the record of the inspection.

(d) HHSC [~~DADS~~] provides a written notification of the inspection results to the center no later than 10 business days after the exit conference. The written notification includes a statement of violations and instructions for submitting an acceptable plan of correction and provides an opportunity for an informal dispute resolution (IDR).

(e) If a center receives HHSC [~~DADS~~] written notification of the inspection results indicating that the center is in violation of THSC Chapter 248A or this chapter, the center must follow HHSC [~~DADS~~] instructions included with the notification for submitting an acceptable plan of correction.

(f) If required, a center must submit an acceptable plan of correction that includes the corrective measures and time frame in which the center will comply to ensure correction of a violation. If a center fails to correct each violation by the date on the plan of correction, HHSC [~~DADS~~] may take enforcement action against the center.

(g) A center must submit an acceptable plan of correction for each violation no later than 10 calendar days after receipt of the [~~DADS~~] written notification of the inspection results. An acceptable plan of correction must address:

(1) how the center will accomplish corrective action for the minors affected by the violation;

(2) how the center will identify other minors with the potential to be affected by the same violation;

(3) the measures that the center will incorporate, or systemic changes the center made to ensure the violation will not recur;

(4) how the center will monitor its corrective actions to ensure that the violation is corrected and will not recur; and

(5) dates when the center's corrective action will be completed.

(h) A center's acceptable plan of correction does not preclude HHSC [~~DADS~~] from taking enforcement action against the center in accordance with Subchapter G of this chapter (relating to Enforcement).

(i) A center must submit a plan of correction in response to the [~~DADS~~] written notification of inspection results that specifies a violation even if the center disagrees with the inspection results.

(j) If a center disagrees with the inspection results, the center may request an IDR [~~informal dispute resolution (IDR)~~]. The center must submit a written request and all supporting documentation to HHSC [~~DADS~~] no later than the 10th calendar day after the date the center receives HHSC [~~DADS~~] statement of violations.

(k) A center waives its right to an IDR if the center fails to submit the required information to the HHSC [~~DADS~~ ] Regulatory Services, Survey and Certification Enforcement Unit, within the required time frames.

(l) A center must make available to any person on request a copy of each HHSC [~~DADS~~] inspection report. Before making an inspection report available under this subsection, the center must redact from the report any information that is confidential under other law.

(m) A center must post the most recent inspection results in a conspicuous location at the center.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402407

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161

SUBCHAPTER G. ENFORCEMENT

26 TAC §§550.1401 - 550.1408

STATUTORY AUTHORITY

The amendments implement Texas Government Code §531.0055 and Texas Human Resources Code, Chapter 103.

§550.1401.Denial of License Application.

HHSC [~~DADS~~] may deny a license application for the reasons described in §550.115 [~~§15.115~~] of this chapter (relating to Criteria for Denial of a License).

§550.1402.License Suspension.

(a) HHSC [~~DADS~~] may suspend a center's license for:

(1) a violation of THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;

(2) an intentional or negligent act by a center or an employee of a center that HHSC [~~DADS~~] determines significantly affects the health and safety of a minor served at a center;

(3) use of drugs or intoxicating liquors to an extent that it affects the license holder's or applicant's professional competence;

(4) a felony conviction, including a finding or verdict of guilty, an admission of guilt, or a plea of nolo contendere, in Texas or another state of any person required by this chapter to undergo a background and criminal history check;

(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception committed by any person listed on the application;

(6) license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed in the application;

(8) aiding, abetting, or permitting a violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;

(9) a license holder or applicant's failure to provide the required information, facts, or references;

(10) a license holder or applicant who knowingly:

(A) submits false or intentionally misleading statements to HHSC [~~DADS~~] on an application;

(B) uses subterfuge or other evasive means of filing an application;

(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or

(D) conceals a material fact on an application; or

(11) a person listed on the application failing to pay the following fees, taxes, and assessments when due:

(A) licensing fees as described in §550.112 [~~§15.112~~] of this chapter (relating to Licensing Fees);

(B) plan review fees as described in §550.113 [~~§15.113~~] of this chapter (relating to Plan Review Fees); or

(b) HHSC [~~DADS~~] may suspend a license simultaneously with any other enforcement action available to HHSC [~~DADS~~].

(c) HHSC [~~DADS~~] notifies the license holder by personal service, facsimile transmission, or registered or certified mail of its [~~DADS~~] intent to suspend the license, including the facts or conduct alleged to warrant the suspension.

(d) The license holder has an opportunity to show compliance with all requirements of law to retain the license, as provided in §550.1407 [~~§15.1407~~] of this subchapter (relating to Opportunity to Show Compliance). If the license holder requests an opportunity to show compliance, HHSC [~~DADS~~] gives the license holder a written affirmation or reversal of the proposed action.

(e) HHSC [~~DADS~~] notifies the license holder by personal services, facsimile transmission, or by registered or certified mail of its [~~DADS~~] suspension of the center license. The license holder has 20 days after receipt of the notice to request a hearing in accordance with Texas Government Code, Chapter 2001, and the formal hearing procedures in 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act) and Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act). The license suspension takes effect when the deadline for an appeal of the suspension expires, unless the license holder appeals the suspension.

(f) If a license holder appeals, the license remains valid until all administrative appeals are final, unless the license expires without a timely application for renewal submitted to HHSC [~~DADS~~]. The license holder must continue to submit a renewal application in accordance with §550.106 [~~§15.106~~ ] of this chapter (relating to Renewal License Application Procedures and Issuance) until the action to suspend the license is completed. However, HHSC [~~DADS~~] does not renew the license until it determines the reason for the proposed action no longer exists.

(g) If a license holder appeals, the enforcement action takes effect when all administrative appeals are final and the proposed enforcement action is upheld. If the center wins the appeal, HHSC [~~DADS~~] does not take the proposed action.

(h) If HHSC [~~DADS~~] suspends a license, the suspension remains in effect until HHSC [~~DADS~~ ] determines that the reason for suspension no longer exists. A suspension may last no longer than the term of the license. HHSC [~~DADS~~] conducts an on-site investigation before making a determination. During the suspension, the license holder must return the license to HHSC [~~DADS~~].

§550.1403.Emergency License Suspension.

(a) HHSC [~~DADS~~] may issue an emergency order to suspend a license, as authorized by THSC Chapter 248A, if HHSC [~~DADS~~] has reasonable cause to believe that the conduct of a license holder creates an immediate danger to a minor served at the center or the public's health and safety.

(1) If HHSC [~~DADS~~] issues an order for emergency suspension of the center's license, HHSC [~~DADS~~] provides immediate notice to the controlling person, administrator, or alternate administrator of the center by personal service, facsimile transmission, or registered or certified mail. The notice includes:

(A) the action taken;

(B) legal grounds for the action;

(D) the effective date of the order.

(2) An order for emergency licensure suspension goes into effect immediately.

(3) On written request of a license holder, HHSC [~~DADS~~] conducts a hearing not earlier than the 10th day, or later than [~~then~~] the 30th day after, the date HHSC [~~DADS~~] receives the hearing request to determine if the emergency suspension should be continued, modified, or rescinded.

(4) The hearing and any appeal are governed by HHSC [~~DADS~~] rules for a contested case hearing and by Texas Government Code, Chapter 2001 [~~, Texas Government Code~~].

(b) If HHSC [~~DADS~~] suspends a license, the suspension remains in effect until HHSC [~~DADS~~ ] determines that the reason for an emergency licensure suspension no longer exists. An emergency licensure suspension may last no longer than the term of the license. HHSC [~~DADS~~] conducts an inspection of the center before making a determination to recommend cancellation of a suspension. During the suspension, the license holder must return the license to HHSC [~~DADS~~].

§550.1404.License Revocation.

(a) HHSC [~~DADS~~] may revoke a center's license for:

(1) a violation of THSC Chapter 248A or a standard in this chapter committed by the license holder, applicant, or a person listed on the application;

(2) an intentional or negligent act by a center or an employee of a center that HHSC [~~DADS~~] determines significantly affects the health and safety of a minor served at a center;

(3) use of drugs or intoxicating liquors to an extent that affects the license holder's or applicant's professional competence;

(5) fraudulent acts, including acts relating to Medicaid fraud and obtaining or attempting to obtain a license by fraud or deception committed by any person listed on the application;

(6) license revocation, suspension, or other disciplinary action taken in Texas or another state against the license holder or any person listed in the application;

(8) aiding, abetting, or permitting a violation described in paragraph (1) of this subsection about which a person listed on the application had or should have had knowledge;

(9) a license holder or applicant's failure to provide the required information, facts, or references;

(10) a license holder or applicant who knowingly:

(A) submits false or intentionally misleading statements to HHSC [~~DADS~~] on an application;

(B) uses subterfuge or other evasive means of filing an application;

(C) engages in subterfuge or other evasive means of filing an application on behalf of another who is unqualified for licensure; or

(D) conceals a material fact on an application;

(11) a person listed on the application committing fraud; or

(12) a person listed on the application failing to pay the following fees, taxes, and assessments when due:

(A) licensing fees as described in §550.112 [~~§15.112~~] of this chapter (relating to Licensing Fees);

(B) plan review fees as described in §550.113 [~~§15.113~~] of this chapter (relating to Plan Review Fees); and

(b) HHSC [~~DADS~~] may revoke a license simultaneously with any other enforcement action available to HHSC [~~DADS~~].

(c) HHSC [~~DADS~~] notifies the license holder by personal service, facsimile transmission, registered or certified mail of its [~~DADS~~] intent to revoke the license, including the facts or conduct alleged to warrant the revocation, and sends a copy to the center. The license holder has an opportunity to show compliance with all requirements of the law to retain the license, as provided in §550.1407 [~~§15.1407~~ ] of this subchapter (relating to Opportunity to Show Compliance). If the license holder requests an opportunity to show compliance, HHSC [~~DADS~~] gives the license holder a written affirmation or reversal of the proposed action.

(d) HHSC [~~DADS~~] notifies a license holder by personal service, facsimile transmission, or by registered or certified mail of its [~~DADS~~] revocation of the center license and sends a copy to the center. The license holder has 20 days after receipt of the notice to request a hearing in accordance with the HHSC [~~Health and Human Services Commission's~~] formal hearing procedures in 1 Texas Administrative Code [~~TAC~~] Chapter 357, Subchapter I (relating to Hearings Under the Administrative Procedure Act), and HHSC [~~DADS~~] formal hearing procedures in Chapter 110 [91] of this title (relating to Hearings Under the Administrative Procedure Act). The revocation takes effect when the deadline for appeal of the revocation expires unless the license holder appeals the revocation.

(e) If a license holder appeals, the license remains valid until all appeals are final, unless the license expires without a timely application for renewal submitted to HHSC [~~DADS~~]. The license holder must continue to submit a renewal application in accordance with §550.106 [~~§15.106~~] of this chapter (relating to Renewal Application Procedures and Issuance) until the action to revoke the license is completed. However, HHSC [~~DADS~~] does not renew the license until it determines the reason for the proposed action no longer exists.

(f) If a license holder appeals, the enforcement action takes effect when all appeals are final and the proposed enforcement action is upheld. Upon revocation, the license must be returned to HHSC [~~DADS~~]. If the license holder wins the appeal, HHSC [~~DADS~~] does not take the proposed action.

§550.1405.Probation.

If HHSC [~~DADS~~] finds that a center is in repeated noncompliance with THSC Chapter 248A, this chapter or a plan of correction, but the noncompliance does not endanger a minor served at a center or the public health and safety, HHSC [~~DADS~~] may schedule the center for probation rather than suspending or revoking the center's license.

(1) HHSC [~~DADS~~] provides notice to the license holder of the probation and the items of noncompliance not later than the 10th day before the date the probation period begins.

(2) HHSC [~~DADS~~] designates a period of not less than 30 days during which the center remains on probation. During the probation period, the center must correct the items that were in noncompliance and report the corrections to HHSC [~~DADS~~] for approval.

(3) HHSC [~~DADS~~] may suspend or revoke the license of a center that does not correct items that were in noncompliance or does not comply with THSC Chapter 248A or this chapter within the applicable probation period.

§550.1406.Injunctive Relief or Civil Penalties.

(a) HHSC [~~DADS~~] may petition a district court for a temporary restraining order against a center to restrain a continuing violation of THSC Chapter 248A or standard in this chapter if HHSC [~~DADS~~] finds that the violation creates an immediate threat to the health and safety of minors served at a center.

(b) A district court, on petition of HHSC [~~DADS~~], and on a finding of the court that a person is violating THSC Chapter 248A or a standard in this chapter, may by injunction:

(1) prohibit the person from continuing the violation;

(2) restrain or prevent the establishment or operation of a center without a license under THSC Chapter 248A; or

(3) grant any other injunctive relief warranted by the facts.

(d) HHSC [~~DADS~~] may recover reasonable expenses incurred in obtaining relief under this section, including court costs, reasonable attorney's fees, investigation costs, witness fees, and deposition expenses.

(e) Venue for a suit brought under this section is in the county in which the center is located or in Travis County.

(f) If HHSC [~~DADS~~] determines that a violation of THSC Chapter 248A or a standard in this chapter threatens the health and safety of a minor served at the center, HHSC [~~DADS~~] may seek, against the person who violates THSC Chapter 248A, the requirements in this chapter, or fails to comply with a corrective action plan submitted in accordance with this chapter, a civil penalty of not more than $500 for each violation.

(1) Each day a violation continues constitutes a separate violation for the purpose of this section.

(2) HHSC [~~DADS~~] may request the attorney general to sue to collect the penalty. HHSC [~~DADS~~ ] may recover reasonable expenses incurred in obtaining relief under this section, including court costs, reasonable attorney fees, investigation costs, witness fees, and deposition expenses.

§550.1407.Opportunity to Show Compliance.

(a) Before revocation or suspension of a center's license or denial of an application for the renewal of a center's license, HHSC [~~DADS~~] gives the license holder:

(1) a notice by personal service, facsimile transmission, or by registered or certified mail of the facts or conduct alleged to warrant the proposed action, with a copy sent to the center; and

(2) an opportunity to show compliance with all requirements of law to retain the license by sending HHSC [~~DADS~~] a written request that [~~. The request~~] must:

(A) be postmarked no later than 10 days after the date of HHSC [~~DADS~~] notice and be received in HHSC [~~DADS~~] office no later than 10 days after the date of the postmark;and

(B) contain specific documentation refuting HHSC [~~DADS~~] allegations.

(b) HHSC [~~DADS~~] limits its review to the documentation submitted by the license holder and information HHSC [~~DADS~~] used as the basis for its proposed action. A license holder or center representative may not attend the [~~DADS~~] meeting to review the opportunity to show compliance documents. HHSC [~~DADS~~] gives a license holder a written affirmation or reversal of the proposed action.

(1) informs the license holder of its [~~DADS~~ ] decision; and

(2) provides the license holder with an opportunity to appeal the [~~DADS~~] decision through a formal hearing process, if HHSC [~~DADS~~] affirms the proposed action.

§550.1408.Administrative Penalties.

(a) The following words and terms, when used in this section, have the following meanings unless the context clearly indicates otherwise.

(1) Actual harm--A negative outcome that compromises a minor's physical, mental, or emotional well-being.

(2) Immediate threat to the health or safety of a minor--A situation that causes, or is likely to cause, serious injury, harm, or impairment to or the death of a minor.

(3) Isolated--A very limited number of minors are affected and a very limited number of staff are involved, or the situation has occurred only occasionally.

(4) Pattern of violation--Repeated, but not widespread in scope, failures of a center to comply with THSC Chapter 248A or a rule, standard, or order adopted under THSC Chapter 248A that:

(A) result in a violation; and

(B) are found throughout the services provided by the center or that affect or involve the same minor or center employees.

(5) Potential for minimal harm--A violation that has the potential for causing no more than a minor negative impact on a minor.

(6) Widespread in scope--A violation that:

(A) is pervasive throughout the services provided by the center; or

(B) represents a systemic failure by the center that affects or has the potential to affect a large portion of or all of the minors of the center.

(b) Assessing penalties. HHSC may assess an administrative penalty against a person who violates:

(1) THSC, Chapter 248A; or

(2) a provision in this chapter for which a penalty may be assessed.

(c) Criteria for assessing penalties. HHSC assesses an administrative penalty based on the scope and severity of a violation in accordance with the table in this section. Within an established range, HHSC determines the amount of an administrative penalty based on the following criteria:

(1) the seriousness of the violation, including the nature, circumstances, extent, and gravity of the violation;

(2) the threat to the health or safety caused by the violation;

(3) any previous violations;

(4) the amount necessary to deter future violations;

(5) efforts made by the violator to correct the violation; and

(6) any other matters that justice may require.

(d) Penalty calculation and assessment. The table in this section sets forth the ranges for administrative penalties that HHSC assesses, based on the scope and severity of a violation. An administrative penalty may not exceed $500 for each violation. Each day a violation continues or occurs is a separate violation for purposes of imposing a penalty.

(e) Schedule of appropriate and graduated penalties.

(f) The penalty range for a Severity Level A violation is $400 - $500 per violation.

(g) A Severity Level A violation is a violation that results in immediate threat to a minor's health or safety.

(h) The penalty range for a Severity Level B violation is $300 - $400 per violation.

(i) A Severity Level B violation is a violation that results in actual harm that is not considered an immediate threat.

(j) The penalty range for a Severity Level C violation is $200 - $300 per violation.

(k) A Severity Level C violation is a violation with no actual harm with potential for more than minimal harm.

(l) The penalty range for a Severity Level D violation is $100 - $200 per violation.

(m) A Severity Level D violation is a violation with no actual harm with potential for minimal harm.

Figure: 26 TAC §550.1408(m) (.pdf)

[~~Figure: 40 TAC §15.1408(m)~~]

(n) Proposal of administrative penalties. If HHSC assesses an administrative penalty, HHSC provides a written notice of violation letter to a center. The notice includes:

(1) a brief summary of the violation;

(2) the amount of the proposed penalty; and

(3) a statement of the center's right to a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both the occurrence of the violation and the amount of the penalty.

(o) A center may accept the [~~HHSC's~~] determination and recommended penalty not later than 20 days after the date on which the center receives the notice of violation letter, including the proposed penalty, or make a written request for a formal administrative hearing on the occurrence of the violation, the amount of the penalty, or both.

(1) If a center that is notified of a violation accepts the [~~HHSC's~~] determination and recommended penalty or fails to respond to the notice, the executive commissioner or designee issues an order approving the determination and ordering that the center pay the proposed penalty.

(2) If a center that is notified of a violation does not accept the [~~HHSC's~~] determination, the center must submit to HHSC a written request for a formal administrative hearing on the determination and must not pay the proposed penalty. Remittance of the penalty to HHSC is deemed acceptance by the center that the [~~of HHSC's~~] determination is final, and the center waives the center's right to a formal administrative hearing.

(3) If a center requests a formal administrative hearing, the hearing is held in accordance with THSC §248A.255.

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 29, 2024.

TRD-202402408

Karen Ray

Chief Counsel

Health and Human Services Commission

Earliest possible date of adoption: July 14, 2024

For further information, please call: (512) 438-3161